Basic Information
| Provider Information | |||||||||
| NPI: | 1285163477 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL HOME ALLIANCE LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | IMA DOWNTOWN KISSIMMEE DISPENSARY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD STE 475 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 431 W OAK ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347416627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2017 | ||||||||
| LastUpdateDate: | 06/29/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PICHARDO | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4078450330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INHEALTH MD ALLIANCE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.