Provider Demographics
NPI:1972061679
Name:INTERVENTIONAL ASSOCIATES OF LEESBURG, LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL ASSOCIATES OF LEESBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-702-4340
Mailing Address - Street 1:425 ALEXANDRIA BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5548
Mailing Address - Country:US
Mailing Address - Phone:407-977-3434
Mailing Address - Fax:
Practice Address - Street 1:106 W NORTH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5039
Practice Address - Country:US
Practice Address - Phone:352-702-4340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty