Basic Information
| Provider Information | |||||||||
| NPI: | 1215280003 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXODUS WOMEN'S CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 S PARSONS AVE | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335116007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842229 | ||||||||
| FaxNumber: | 8136541384 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 W DR MARTIN LUTHER KING JR BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2012 | ||||||||
| LastUpdateDate: | 06/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | MAYO | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8136842229 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 057571216 | 05 | FL | MEDICAID |