Provider Demographics
NPI:1134638257
Name:IMPLAGRAFT LLC
Entity type:Organization
Organization Name:IMPLAGRAFT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-484-2098
Mailing Address - Street 1:P.O. BOX 560569
Mailing Address - Street 2:
Mailing Address - City:MONTVERDE
Mailing Address - State:FL
Mailing Address - Zip Code:34756-9998
Mailing Address - Country:US
Mailing Address - Phone:407-484-2098
Mailing Address - Fax:407-386-8587
Practice Address - Street 1:12701 MAGNOLIA BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8144
Practice Address - Country:US
Practice Address - Phone:407-484-2098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies