=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356047807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE VITAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2023
-----------------------------------------------------
Last Update Date | 02/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7827 N DALE MABRY HWY STE 108
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-808-0538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7827 N DALE MABRY HWY STE 108
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-808-0538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWER
-----------------------------------------------------
Name | YUBISLEY GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-808-0538
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------