MEDICARE: ULTRA MEDICAL 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1972133163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTRA MEDICAL LLC

Provider Business Mailing Address
First Line	:	10350 PINES BLVD STE D103
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33026-6051
Country	:	US
Telephone Number	:	754-210-2460
Fax Number	:

Provider Business Practice Location Address
First Line	:	10350 PINES BLVD STE D103
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33026-6051
Country	:	US
Telephone Number	:	754-210-2460
Fax Number	:

Authorized Official
Title or Position	:	VP OPERATIONS
Name	:	MR. ALFREDO INFANTE
Credential	:
Telephone Number	:	754-210-2460

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	01/16/2020

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