MEDICARE: UNDERSEA OXYGEN 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	261Q00000X	Clinic/Center	IBUM-2343-0010	FL

General Provider Information

NPI Number	:	1427569920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNDERSEA OXYGEN CLINIC LLC

Provider Business Mailing Address
First Line	:	701 N WEST SHORE BLVD FL 3
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-1122
Country	:	US
Telephone Number	:	813-533-7093
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 N WEST SHORE BLVD FL 3
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-1122
Country	:	US
Telephone Number	:	813-533-7093
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PROF. JOSEPH DITURI
Credential	:	PHD(C)
Telephone Number	:	813-533-7095

Provider Enumeration Date	:	10/24/2017
Last Update Date	:	01/03/2018

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