=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750027660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BON VITAS MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2022
-----------------------------------------------------
Last Update Date | 05/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5979 VINELAND RD STE 209
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-7855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-592-0949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15520 WATERLEIGH COVE DR
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-9208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-592-0949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MELISSA ORTIZ MIRANDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-592-0949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------