Healthcare Provider Details

I. General information

NPI: 1366165607
Provider Name (Legal Business Name): ISLAND ENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 VENETIA BAY BLVD STE 350
VENICE FL
34285-8052
US

IV. Provider business mailing address

901 VENETIA BAY BLVD STE 350
VENICE FL
34285-8052
US

V. Phone/Fax

Practice location:
  • Phone: 941-786-0386
  • Fax: 941-786-0386
Mailing address:
  • Phone: 941-786-0386
  • Fax: 941-786-0386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: MRS. HEATHER JOY CLARK
Title or Position: BUSINESS OWNER/ MANAGER
Credential:
Phone: 941-786-0386