Provider Demographics
NPI:1942829536
Name:HEALTH MEDICAL ULTRA LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:HEALTH MEDICAL ULTRA LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-399-5995
Mailing Address - Street 1:1760 HAVENDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-1224
Mailing Address - Country:US
Mailing Address - Phone:939-235-8227
Mailing Address - Fax:
Practice Address - Street 1:1760 HAVENDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1224
Practice Address - Country:US
Practice Address - Phone:863-662-3007
Practice Address - Fax:863-875-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100166000Medicaid