Provider Demographics
NPI:1376965822
Name:ADVANCED SURGICAL & WEIGHT LOSS INSTITUTE LLC
Entity Type:Organization
Organization Name:ADVANCED SURGICAL & WEIGHT LOSS INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:
Authorized Official - Last Name:VELARDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-549-2273
Mailing Address - Street 1:375 S COURTENAY PKWY
Mailing Address - Street 2:SUITE 7 A
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4886
Mailing Address - Country:US
Mailing Address - Phone:321-549-2273
Mailing Address - Fax:321-549-2066
Practice Address - Street 1:375 S COURTENAY PKWY
Practice Address - Street 2:SUITE 7A
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4886
Practice Address - Country:US
Practice Address - Phone:321-549-2273
Practice Address - Fax:321-549-2066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 94651208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000052100Medicaid