Healthcare Provider Details

I. General information

NPI: 1912665423
Provider Name (Legal Business Name): MC MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28500 FL-54
WESLEY CHAPEL FL
33543-3210
US

IV. Provider business mailing address

702 SW 8TH ST # MS 0445
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 813-345-3829
  • Fax:
Mailing address:
  • Phone: 479-204-1258
  • Fax: 479-277-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SOUJANYA PULLURU
Title or Position: OWNER
Credential:
Phone: 479-204-1258