Provider Demographics
NPI:1821751959
Name:BUSCHE, WOLMAR GEORGE
Entity Type:Individual
Prefix:
First Name:WOLMAR
Middle Name:GEORGE
Last Name:BUSCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 LESLIE RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-2224
Mailing Address - Country:US
Mailing Address - Phone:813-299-1602
Mailing Address - Fax:
Practice Address - Street 1:3115 S MILLER RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5716
Practice Address - Country:US
Practice Address - Phone:813-530-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12342310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility