Provider Demographics
NPI:1316205123
Name:UGA STREET, INC
Entity Type:Organization
Organization Name:UGA STREET, INC
Other - Org Name:UGA STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOYE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH,
Authorized Official - Phone:813-248-1621
Mailing Address - Street 1:PO BOX 310256
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33680-0256
Mailing Address - Country:US
Mailing Address - Phone:813-248-1621
Mailing Address - Fax:813-248-5408
Practice Address - Street 1:3302 E. MARTIN LUTHER KING JR BLVD. #101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610
Practice Address - Country:US
Practice Address - Phone:813-248-1621
Practice Address - Fax:813-248-5408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UGA STREET, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC009401261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center