=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639863467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. FUSION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2023
-----------------------------------------------------
Last Update Date | 06/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4019 US HIGHWAY 98 N
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33809-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-209-7282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5337 N SOCRUM LOOP RD # 105
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33809-4256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-209-7282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULYSSA COLON
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 862-209-7282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------