Healthcare Provider Details

I. General information

NPI: 1083801609
Provider Name (Legal Business Name): VALRICO MEDICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 LITHIA PINECREST RD
VALRICO FL
33596-5632
US

IV. Provider business mailing address

3119 LITHIA PINECREST RD
VALRICO FL
33596-5632
US

V. Phone/Fax

Practice location:
  • Phone: 813-643-3242
  • Fax:
Mailing address:
  • Phone: 813-643-3242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME83318
License Number StateFL

VIII. Authorized Official

Name: MR. SYDNEY SHAW
Title or Position: OFFICE MANAGER
Credential:
Phone: 813-643-3242