Provider Demographics
NPI:1801811443
Name:PHYSICIANS OF WINTER HAVEN LLC
Entity type:Organization
Organization Name:PHYSICIANS OF WINTER HAVEN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-293-8471
Mailing Address - Street 1:2400 DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-1166
Mailing Address - Country:US
Mailing Address - Phone:863-293-8471
Mailing Address - Fax:863-508-1390
Practice Address - Street 1:2400 DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1166
Practice Address - Country:US
Practice Address - Phone:863-293-8471
Practice Address - Fax:863-508-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1246261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1467Medicare ID - Type UnspecifiedPROVIDER NUMBER