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General NPI Number Information
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NPI Number | 1295151330
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Entity Type | Organization
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Legal Business Name | ELEMENTZ RX
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Dates
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Enumeration Date | 03/13/2014
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Last Update Date | 03/13/2014
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Provider Practice Location Address
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Address Line | 6124 53RD AVE E
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City | BRADENTON
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State | FL
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Zip | 34203-9707
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Country | US
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Telephone | 941-448-1199
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Fax | 941-761-5690
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Provider Business Mailing Address
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Address Line | 6124 53RD AVE E
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City | BRADENTON
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State | FL
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Zip | 34203-9707
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Country | US
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Telephone | 941-448-1199
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Fax | 941-761-5690
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. GEORGE BINO RUCKER
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Credential | M.D
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Telephone | 941-448-1199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | ME82623
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License Number State | FL
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