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NPI Code Detail

MEDICARE: IMPERIAL BOULEVARD MANAGEMENT,LLC

MEDICARE: IMPERIAL BOULEVARD MANAGEMENT,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
1122300000XDentist1190925FL

General Provider Information

NPI Number : 1851557078
Entity Type Code : Organization
Provider Name (Legal Business Name) : IMPERIAL BOULEVARD MANAGEMENT,LLC
Provider Business Mailing Address
First Line : 225 IMPERIAL BLVD
Second Line :
City : LAKELAND
State : FL
Zip : 33803-4612
Country : US
Telephone Number : 863-644-4739
Fax Number : 863-644-1333
Provider Business Practice Location Address
First Line : 225 IMPERIAL BLVD
Second Line :
City : LAKELAND
State : FL
Zip : 33803-4612
Country : US
Telephone Number : 863-644-4739
Fax Number : 863-644-1333
Authorized Official
Title or Position : TURSTEE
Name : ANGEL NICHOLS
Credential :
Telephone Number : 863-644-4739
Provider Enumeration Date : 08/07/2008
Last Update Date : 08/07/2008

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Directions to “IMPERIAL BOULEVARD MANAGEMENT,LLC ” Practice Location

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