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General NPI Number Information
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NPI Number | 1649026428
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Entity Type | Organization
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Legal Business Name | AMERICAN VITALITY MEDICAL GROUP, LLC.
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Dates
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Enumeration Date | 04/24/2024
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Last Update Date | 04/24/2024
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Provider Practice Location Address
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Address Line | 4120 CORLEY ISLAND RD STE 500
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City | LEESBURG
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State | FL
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Zip | 34748-8297
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Country | US
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Telephone | 727-415-7253
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 LAKE DORA DR
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City | TAVARES
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State | FL
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Zip | 32778-3529
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Country | US
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Telephone | 727-415-7253
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. DOUGLAS RODANTE
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Credential |
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Telephone | 727-415-7253
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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 | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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