=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790905792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHECKUPS - FL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11910 BRUCE B DOWNS BLVD
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-760-0050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1359 BROADWAY
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-7102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-760-0050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O.
-----------------------------------------------------
Name | MR. JACK TAWIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-760-0050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------