MEDICARE: 1977 ENTERPRISE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207QS0010X	Sports Medicine (Family Medicine) Physician
2	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician
3	2084P0800X	Psychiatry Physician
4	208M00000X	Hospitalist Physician
5	363A00000X	Physician Assistant
6	363LA2200X	Adult Health Nurse Practitioner
7	363LF0000X	Family Nurse Practitioner
8	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
9	363LP2300X	Primary Care Nurse Practitioner
10	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1952009995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1977 ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	450 S ORANGE AVE FL 3
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-3394
Country	:	US
Telephone Number	:	407-212-7113
Fax Number	:	407-264-8686

Provider Business Practice Location Address
First Line	:	450 S ORANGE AVE FL 3
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-3394
Country	:	US
Telephone Number	:	407-212-7113
Fax Number	:	407-264-8686

Authorized Official
Title or Position	:	CEO
Name	:	MARISSA EARLY
Credential	:
Telephone Number	:	407-212-7113

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	03/08/2024

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Directions to “1977 ENTERPRISE LLC ” Practice Location

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