MEDICARE: MEND VIP, INC

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	207Q00000X	Family Medicine Physician	OS4294	FL

General Provider Information

NPI Number	:	1437546900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEND VIP, INC

Provider Business Mailing Address
First Line	:	4767 NEW BROAD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-6405
Country	:	US
Telephone Number	:	407-848-1013
Fax Number	:

Provider Business Practice Location Address
First Line	:	4767 NEW BROAD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-6405
Country	:	US
Telephone Number	:	407-848-1013
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MATTHEW MCBRIDE
Credential	:
Telephone Number	:	734-748-1079

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/22/2015

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