Provider Demographics
NPI:1437496882
Name:OPTUMCARE FLORIDA, LLC
Entity Type:Organization
Organization Name:OPTUMCARE FLORIDA, LLC
Other - Org Name:JSA MEDICAL GROUP SUN CITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:10051 5TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:733 CORTARO DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33573-6812
Practice Address - Country:US
Practice Address - Phone:813-634-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-04
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83064332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site