Provider Demographics
NPI:1821372129
Name:CYPRESS CREEK MEDICAL SPA
Entity Type:Organization
Organization Name:CYPRESS CREEK MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-948-3838
Mailing Address - Street 1:26827 FOGGY CREEK RD
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6768
Mailing Address - Country:US
Mailing Address - Phone:813-973-7774
Mailing Address - Fax:813-973-8882
Practice Address - Street 1:1942 HIGHLAND OAKS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7410
Practice Address - Country:US
Practice Address - Phone:813-948-3838
Practice Address - Fax:813-949-0629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILYCARE OF LAND O LAKES, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0048283207Q00000X
FL0040424207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34555OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FLCN4592OtherRAILROAD RETIREMENT
FL34555OtherBLUE CROSS BLUE SHIELD OF FLORIDA