=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063216471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEIGHT STREET VENTURES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2025
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2851 HEIGHT STREET
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-893-4900
-----------------------------------------------------
Fax | 941-298-0040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6050 CATTLERIDGE BLVD STE 201
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34232-6028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-893-4900
-----------------------------------------------------
Fax | 941-298-0040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MICHAEL MOUSTOUKAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-893-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------