MEDICARE: OPTUMCARE FLORIDA, 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	332900000X	Non-Pharmacy Dispensing Site	ME87898	FL

General Provider Information

NPI Number	:	1780051714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTUMCARE FLORIDA, LLC

Provider Business Mailing Address
First Line	:	10051 5TH STREET N.
Second Line	:
City	:	ST. PETERSBURG
State	:	FL
Zip	:	33702
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	931 10TH ST E
Second Line	:
City	:	PALMETTO
State	:	FL
Zip	:	34221-4131
Country	:	US
Telephone Number	:	941-847-7903
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	JOHN G. LIETHEN
Credential	:
Telephone Number	:	952-205-6262

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	08/19/2019

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