Healthcare Provider Details

I. General information

NPI: 1154002772
Provider Name (Legal Business Name): MVC FL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 ARGYLE RD
WEST PALM BEACH FL
33405-1605
US

IV. Provider business mailing address

7125 ORCHARD LAKE RD STE 316
WEST BLOOMFIELD MI
48322-3629
US

V. Phone/Fax

Practice location:
  • Phone: 488-555-3552
  • Fax:
Mailing address:
  • Phone: 248-855-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY DESANTIS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 248-847-4925