=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659749943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTUMCARE FLORIDA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 08/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 W BLOOMINGDALE AVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-7402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-653-1880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5626 OBERLIN DR SUITE 110
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | JOHN G. LIETHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-205-6262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | ME79514
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------