Provider Demographics
NPI:1639898380
Name:CARDIOVASCULAR INSTITUTE OF NW FLORIDA CENTER OF EXCELLENCE, LLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR INSTITUTE OF NW FLORIDA CENTER OF EXCELLENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-274-6549
Mailing Address - Street 1:13830 SAWYER RANCH RD STE 105
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-5514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 W BALDWIN RD STE D
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3359
Practice Address - Country:US
Practice Address - Phone:210-621-5621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-25
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty