Provider Demographics
NPI:1437429073
Name:CELEBRITY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:CELEBRITY MEDICAL CENTER LLC
Other - Org Name:CELEBRITY MEDICAL SPA, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELDAR
Authorized Official - Middle Name:BOLATOVICH
Authorized Official - Last Name:BAIGABATOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-347-9886
Mailing Address - Street 1:36 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3125
Mailing Address - Country:US
Mailing Address - Phone:407-347-9886
Mailing Address - Fax:407-387-9887
Practice Address - Street 1:36 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3125
Practice Address - Country:US
Practice Address - Phone:407-347-9886
Practice Address - Fax:407-387-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007VROtherFL BLUE
FL007VROtherFL BLUE