Provider Demographics
NPI:1992302574
Name:AVITA MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:AVITA MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SEGARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-330-2737
Mailing Address - Street 1:14831 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1825
Mailing Address - Country:US
Mailing Address - Phone:813-210-0982
Mailing Address - Fax:813-210-9205
Practice Address - Street 1:14831 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1825
Practice Address - Country:US
Practice Address - Phone:813-330-2737
Practice Address - Fax:813-210-9205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109041600Medicaid