Provider Demographics
NPI:1316026388
Name:POLK WELLCARE CORP
Entity Type:Organization
Organization Name:POLK WELLCARE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HIMAGIRI
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-293-3909
Mailing Address - Street 1:1045 E COUNTY ROAD 540A
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3735
Mailing Address - Country:US
Mailing Address - Phone:863-293-3909
Mailing Address - Fax:863-293-1909
Practice Address - Street 1:2017 WINDWOOD LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4807
Practice Address - Country:US
Practice Address - Phone:863-293-3909
Practice Address - Fax:863-293-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09852Medicare ID - Type Unspecified