Provider Demographics
NPI:1508119637
Name:CHULUOTA CLINIC, LLC
Entity Type:Organization
Organization Name:CHULUOTA CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-542-7961
Mailing Address - Street 1:107 8TH ST W
Mailing Address - Street 2:
Mailing Address - City:CHULUOTA
Mailing Address - State:FL
Mailing Address - Zip Code:32766-8924
Mailing Address - Country:US
Mailing Address - Phone:407-542-7961
Mailing Address - Fax:
Practice Address - Street 1:107 8TH ST W
Practice Address - Street 2:
Practice Address - City:CHULUOTA
Practice Address - State:FL
Practice Address - Zip Code:32766-8924
Practice Address - Country:US
Practice Address - Phone:407-542-7961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL182428261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care