Provider Demographics
NPI:1255310132
Name:ADVANCED INTERVENTIONAL CARDIOLOGY CONSULTANTS
Entity Type:Organization
Organization Name:ADVANCED INTERVENTIONAL CARDIOLOGY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-679-7985
Mailing Address - Street 1:320 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3750
Mailing Address - Country:US
Mailing Address - Phone:863-679-7985
Mailing Address - Fax:863-679-1865
Practice Address - Street 1:320 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3750
Practice Address - Country:US
Practice Address - Phone:863-679-7985
Practice Address - Fax:863-679-1865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1040Medicare ID - Type Unspecified