MEDICARE: OPULENT MEDICAL CARE 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

General Provider Information

NPI Number	:	1457154379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPULENT MEDICAL CARE LLC

Provider Business Mailing Address
First Line	:	211 E MAIN ST # 435
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4628
Country	:	US
Telephone Number	:	863-944-6977
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 E MAIN ST # 435
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4628
Country	:	US
Telephone Number	:	863-944-6977
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ALICIA SELF
Credential	:	DNP
Telephone Number	:	863-944-6977

Provider Enumeration Date	:	03/27/2025
Last Update Date	:	03/27/2025

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