Basic Information
| Provider Information | |||||||||
| NPI: | 1871187476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTER HAVEN HOSPITAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW STREET EAST BLDG 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819390 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632931121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2021 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7272819479 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINTER HAVEN HOSPITAL INC | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0101699-00 | 05 | FL | MEDICAID | 10D0293341 | 01 | FL | CLIA | OTHER | 152256 | 01 | FL | DEA | OTHER |