Provider Demographics
NPI:1518260090
Name:ST. JUDE MEDICAL & AESTHETIC CARE CENTER, LLC
Entity Type:Organization
Organization Name:ST. JUDE MEDICAL & AESTHETIC CARE CENTER, LLC
Other - Org Name:ST. JUDE MEDICAL CENTER & AESTHETIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:OKOYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-330-6613
Mailing Address - Street 1:4810 PORTOBELLO CIR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596
Mailing Address - Country:US
Mailing Address - Phone:813-315-9898
Mailing Address - Fax:
Practice Address - Street 1:131 N MOON AVE
Practice Address - Street 2:SUITES 3 & 4
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4418
Practice Address - Country:US
Practice Address - Phone:813-315-9898
Practice Address - Fax:813-438-5967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X, 2083P0901X
FLME107980146D00000X, 207QA0401X, 207W00000X, 208D00000X, 208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Multi-Specialty
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208U00000XAllopathic & Osteopathic PhysiciansClinical PharmacologyGroup - Multi-Specialty