Provider Demographics
NPI:1336467208
Name:WATERS MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:WATERS MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:THANHMY
Authorized Official - Middle Name:T
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-885-9091
Mailing Address - Street 1:PO BOX 261825
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33685-1825
Mailing Address - Country:US
Mailing Address - Phone:813-885-9091
Mailing Address - Fax:813-885-3527
Practice Address - Street 1:4040 W WATERS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1958
Practice Address - Country:US
Practice Address - Phone:813-885-9091
Practice Address - Fax:813-885-3527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care