Basic Information
| Provider Information | |||||||||
| NPI: | 1801811443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS OF WINTER HAVEN LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 DUNDEE RD | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338841166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632938471 | ||||||||
| FaxNumber: | 8635081390 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 DUNDEE RD | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338841166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632938471 | ||||||||
| FaxNumber: | 8635081390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VILLARREAL | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8632938471 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1246 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.