Healthcare Provider Details

I. General information

NPI: 1689353609
Provider Name (Legal Business Name): ISLAND HEALTH CONCIERGE MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 HIGHWAY A1A STE 202
VERO BEACH FL
32963-5602
US

IV. Provider business mailing address

PO BOX 643608
VERO BEACH FL
32964-3608
US

V. Phone/Fax

Practice location:
  • Phone: 772-205-6361
  • Fax: 772-410-5477
Mailing address:
  • Phone: 518-763-6969
  • Fax: 772-410-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LATIA H ILYADIS
Title or Position: OWNER
Credential: DO
Phone: 518-763-6969