MEDICARE: OHI WEST MEDICAL GROUP II 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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

General Provider Information

NPI Number	:	1578317012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHI WEST MEDICAL GROUP II LLC

Provider Business Mailing Address
First Line	:	38135 MARKET SQUARE DR
Second Line	:
City	:	ZEPHYRHILLS
State	:	FL
Zip	:	33542-7505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17401 COMMERCE PARK BLVD STE 108
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3507
Country	:	US
Telephone Number	:	813-782-8311
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOE DELATORRE
Credential	:
Telephone Number	:	813-780-8440

Provider Enumeration Date	:	04/12/2024
Last Update Date	:	04/26/2024

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