MEDICARE: MEDICAL GOLDEN CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1073082236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL GOLDEN CLINIC LLC

Provider Business Mailing Address
First Line	:	11310 S ORANGE BLOSSOM TRL STE 109
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-9421
Country	:	US
Telephone Number	:	407-413-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	4365 HUNTERS PARK LN # 10
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-7614
Country	:	US
Telephone Number	:	407-413-3200
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	HECTOR J NIEVES-DAVILA
Credential	:
Telephone Number	:	787-955-6920

Provider Enumeration Date	:	11/16/2018
Last Update Date	:	08/13/2019

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