Healthcare Provider Details

I. General information

NPI: 1801811443
Provider Name (Legal Business Name): PHYSICIANS OF WINTER HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 DUNDEE RD
WINTER HAVEN FL
33884-1166
US

IV. Provider business mailing address

2400 DUNDEE RD
WINTER HAVEN FL
33884-1166
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-8471
  • Fax: 863-508-1390
Mailing address:
  • Phone: 863-293-8471
  • Fax: 863-508-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1246
License Number StateFL

VIII. Authorized Official

Name: DR. JORGE R VILLARREAL
Title or Position: VICE PRESIDENT & MEDICAL DIRECTOR
Credential: M.D.
Phone: 863-293-8471