MEDICARE: DR PROFET HEALTH & WELLNESS CENTER 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	:	1538711643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR PROFET HEALTH & WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	11017 N DALE MABRY HWY STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-3873
Country	:	US
Telephone Number	:	813-337-7402
Fax Number	:	813-461-6462

Provider Business Practice Location Address
First Line	:	11017 N DALE MABRY HWY STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-3873
Country	:	US
Telephone Number	:	813-337-7402
Fax Number	:	813-461-6462

Authorized Official
Title or Position	:	OWNER
Name	:	MARIO PROFET
Credential	:	MD
Telephone Number	:	305-984-0697

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	10/24/2019

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