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General NPI Number Information
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NPI Number | 1922492883
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Entity Type | Organization
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Legal Business Name | OPTUMCARE SOUTH FLORIDA, LLC
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Dates
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Enumeration Date | 03/27/2015
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 9750 NW 33RD ST SUITE 212
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City | CORAL SPRINGS
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State | FL
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Zip | 33065-4042
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Country | US
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Telephone | 954-755-5504
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Fax |
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Provider Business Mailing Address
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Address Line | 10051 5TH STREET NORTH
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City | ST. PETERSBURG
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State | FL
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Zip | 33702-2299
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | JOHN G. LIETHEN
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Credential |
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Telephone | 952-205-6262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | ME94617
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License Number State | FL
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