Healthcare Provider Details

I. General information

NPI: 1528361508
Provider Name (Legal Business Name): CHERYLE JOY ULTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CROSSROADS BLVD
WINTER HAVEN FL
33881-8220
US

IV. Provider business mailing address

1850 CROSSROADS BLVD
WINTER HAVEN FL
33881-8220
US

V. Phone/Fax

Practice location:
  • Phone: 863-326-6790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT16654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: