Basic Information
| Provider Information | |||||||||
| NPI: | 1558937516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONVIVA MEDICAL CENTER MANAGEMENT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONVIVA PLANT CITY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331263168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 228 W ALEXANDER ST | ||||||||
| Address2: | |||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335637157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137545480 | ||||||||
| FaxNumber: | 8772859902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2021 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURGOS | ||||||||
| AuthorizedOfficialFirstName: | OFELIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3055002000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONVIVA MEDICAL CENTER MANAGEMENT LLC | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.