Provider Demographics
NPI:1992435622
Name:PROVITA PHYSICIAN GROUP CORP
Entity type:Organization
Organization Name:PROVITA PHYSICIAN GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-878-9072
Mailing Address - Street 1:3157 N UNIVERSITY DR STE 103
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2258
Mailing Address - Country:US
Mailing Address - Phone:954-322-8985
Mailing Address - Fax:954-322-8981
Practice Address - Street 1:3157 N UNIVERSITY DR STE 103
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2258
Practice Address - Country:US
Practice Address - Phone:954-322-8985
Practice Address - Fax:954-322-8981
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVITA PHYSICIAN GROUP CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15388808OtherCAQH
FLAPRN9243523OtherMEDICAL LICENSE
FLAPRN9243523OtherMEDICAL LICENSE