Healthcare Provider Details

I. General information

NPI: 1942829536
Provider Name (Legal Business Name): HEALTH MEDICAL ULTRA LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 HAVENDALE BLVD NW
WINTER HAVEN FL
33881-1224
US

IV. Provider business mailing address

1760 HAVENDALE BLVD NW
WINTER HAVEN FL
33881-1224
US

V. Phone/Fax

Practice location:
  • Phone: 863-662-3007
  • Fax: 863-875-4681
Mailing address:
  • Phone: 939-235-8227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA I DIEZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 786-399-5995