Healthcare Provider Details

I. General information

NPI: 1205460623
Provider Name (Legal Business Name): GRO MADANM ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 N 56TH ST STE 204
TEMPLE TERRACE FL
33617-3611
US

IV. Provider business mailing address

4377 COMMERCIAL WAY # 103
SPRING HILL FL
34606-1963
US

V. Phone/Fax

Practice location:
  • Phone: 813-364-9928
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: OTNIEL LEFRANC
Title or Position: PRESIDENT
Credential:
Phone: 813-364-9928