Provider Demographics
NPI:1023402088
Name:OPTUMCARE FLORIDA, LLC
Entity Type:Organization
Organization Name:OPTUMCARE FLORIDA, LLC
Other - Org Name:DAVITA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:10051 5TH ST. NORTH
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:770 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4534
Practice Address - Country:US
Practice Address - Phone:813-654-7005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8544332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site