Provider Demographics
NPI:1689353609
Name:ISLAND HEALTH CONCIERGE MEDICINE, INC
Entity Type:Organization
Organization Name:ISLAND HEALTH CONCIERGE MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:ILYADIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:518-763-6969
Mailing Address - Street 1:PO BOX 643608
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32964-3608
Mailing Address - Country:US
Mailing Address - Phone:518-763-6969
Mailing Address - Fax:772-410-5477
Practice Address - Street 1:9301 HIGHWAY A1A STE 202
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-5602
Practice Address - Country:US
Practice Address - Phone:772-205-6361
Practice Address - Fax:772-410-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty