=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194528208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHYCONNECT OF FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2025
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4911 W SAN NICHOLAS ST
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33629-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-334-7442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4030 HENDERSON BLVD STE 598
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33629-4940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | FRED BURRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-334-7442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------