MEDICARE: GREEN LAKE VILLAGE INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1790504694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN LAKE VILLAGE INC

Provider Business Mailing Address
First Line	:	1107 E JACKSON ST STE 208
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-4161
Country	:	US
Telephone Number	:	813-280-1199
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 E JACKSON ST STE 208
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-4161
Country	:	US
Telephone Number	:	813-280-1199
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RICARDO RODRIQUEZ FIGUEROA
Credential	:
Telephone Number	:	813-280-1199

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	10/08/2024

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Directions to “GREEN LAKE VILLAGE INC ” Practice Location

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