Healthcare Provider Details

I. General information

NPI: 1851741763
Provider Name (Legal Business Name): OTHER PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33603-3104
US

IV. Provider business mailing address

714 WEST DR MLK JR BLVD
TAMPA FL
33603
US

V. Phone/Fax

Practice location:
  • Phone: 772-285-7449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: CECILIA A WILLIAMS
Title or Position: ARNP
Credential:
Phone: 772-285-7449