Provider Demographics
NPI:1407625395
Name:INNOVACARE FLORIDA PHYSICIANS, LLC
Entity Type:Organization
Organization Name:INNOVACARE FLORIDA PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-380-1411
Mailing Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7592
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:15689 SOUTHERN BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9229
Practice Address - Country:US
Practice Address - Phone:561-798-3030
Practice Address - Fax:561-798-8242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVACARE FLORIDA PHYSICIANS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty