Provider Demographics
NPI:1801132386
Name:PRO HEALTH HERITAGE SQUARE LLC
Entity type:Organization
Organization Name:PRO HEALTH HERITAGE SQUARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICAPUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-843-7720
Mailing Address - Street 1:2301 NW 33RD CT
Mailing Address - Street 2:SUITE 11
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-1000
Mailing Address - Country:US
Mailing Address - Phone:954-586-8058
Mailing Address - Fax:954-283-1083
Practice Address - Street 1:901 E OAK ST
Practice Address - Street 2:SUITE A
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5837
Practice Address - Country:US
Practice Address - Phone:561-843-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19806207RP1001X
FLME0069080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty