Provider Demographics
NPI:1275200248
Name:INNOVACARE CENTRAL FLORIDA PHYSICIANS, LLC
Entity Type:Organization
Organization Name:INNOVACARE CENTRAL FLORIDA PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-733-7513
Mailing Address - Street 1:1111 7TH AVE N STE 107
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1348
Mailing Address - Country:US
Mailing Address - Phone:727-894-1661
Mailing Address - Fax:
Practice Address - Street 1:1111 7TH AVE N STE 107
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1348
Practice Address - Country:US
Practice Address - Phone:727-894-1661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVACARE CENTRAL FLORIDA PHYSICIANS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty