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General NPI Number Information
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NPI Number | 1689764763
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Entity Type | Organization
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Legal Business Name | HEARTLAND SURGICAL ASSISTANTS, INC
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 200 AVENUE F NE
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City | WINTER HAVEN
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State | FL
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Zip | 33881-4131
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Country | US
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Telephone | 863-381-7647
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Fax |
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Provider Business Mailing Address
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Address Line | 5112 LAKE DEESON WOODS CT
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City | LAKELAND
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State | FL
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Zip | 33805-7638
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Country | US
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Telephone | 863-381-7632
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Fax | 863-606-5713
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEVIN K CARLISLE
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Credential | PAC
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Telephone | 863-381-7632
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA1682
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License Number State | FL
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