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General NPI Number Information
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NPI Number | 1538870696
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Entity Type | Organization
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Legal Business Name | DE LA VEGA MEDICAL GROUP CORPORATION
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Dates
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Enumeration Date | 12/09/2022
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Last Update Date | 01/24/2024
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Provider Practice Location Address
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Address Line | 12781 WORLD PLAZA LN BLDG 88
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City | FORT MYERS
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State | FL
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Zip | 33907-7628
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Country | US
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Telephone | 239-848-9026
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Fax |
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Provider Business Mailing Address
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Address Line | 225 SANTA BARBARA BLVD
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City | CAPE CORAL
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State | FL
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Zip | 33991-2032
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Country | US
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Telephone | 239-848-9026
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Fax |
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Authorized Official
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Title or Position | ARNP-FNP
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Name | JANE LIZ DE LA VEGA
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Credential | NP
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Telephone | 239-848-9026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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