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: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 LAKE DR NW
WINTER HAVEN FL
33881-5008
US

IV. Provider business mailing address

2402 LAKE DR NW
WINTER HAVEN FL
33881-5008
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
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