Provider Demographics
NPI:1932390697
Name:CODIMS OF TAMPA BAY LLC
Entity Type:Organization
Organization Name:CODIMS OF TAMPA BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALIENTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-968-5400
Mailing Address - Street 1:6515 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4021
Mailing Address - Country:US
Mailing Address - Phone:813-968-5400
Mailing Address - Fax:813-968-4433
Practice Address - Street 1:6515 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4021
Practice Address - Country:US
Practice Address - Phone:813-968-5400
Practice Address - Fax:813-968-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15074261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental