Basic Information
| Provider Information | |||||||||
| NPI: | 1821372129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CYPRESS CREEK MEDICAL SPA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26827 FOGGY CREEK RD | ||||||||
| Address2: | SUITE 101A | ||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335446768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139737774 | ||||||||
| FaxNumber: | 8139738882 | ||||||||
| Practice Location | |||||||||
| Address1: | 1942 HIGHLAND OAKS BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335597410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139483838 | ||||||||
| FaxNumber: | 8139490629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSEQUIST | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8139483838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILYCARE OF LAND O LAKES, PA | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0040424 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 0048283 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34555 | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER | CN4592 | 01 | FL | RAILROAD RETIREMENT | OTHER |