MEDICARE: VENEZIA,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	207QA0505X	Adult Medicine Physician	ME103560	FL

General Provider Information

NPI Number	:	1730529488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VENEZIA,LLC

Provider Business Mailing Address
First Line	:	1625 VILLAGE CENTER DR
Second Line	:	APT 203
City	:	LAKELAND
State	:	FL
Zip	:	33803-2868
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 SLEEPY HILL RD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-3800
Country	:	US
Telephone Number	:	863-858-4402
Fax Number	:

Authorized Official
Title or Position	:	FAMILY MEDICINE
Name	:	NICKOLAS SOUMELIDIS
Credential	:	MD
Telephone Number	:	301-401-8051

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	03/07/2023

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