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General NPI Number Information
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NPI Number | 1023402088
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Entity Type | Organization
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Legal Business Name | OPTUMCARE FLORIDA, LLC
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Dates
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Enumeration Date | 03/26/2015
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 770 W DR MARTIN LUTHER KING JR BLVD
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City | SEFFNER
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State | FL
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Zip | 33584-4534
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Country | US
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Telephone | 813-654-7005
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Fax |
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Provider Business Mailing Address
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Address Line | 10051 5TH ST. NORTH
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City | SAINT PETERSBURG
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State | FL
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Zip | 33702
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | JOHN G. LIETHEN
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Credential |
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Telephone | 952-205-6262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | OS8544
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License Number State | FL
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