Provider Demographics
NPI:1447492830
Name:WEST WATERS MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:WEST WATERS MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-734-9218
Mailing Address - Street 1:3550 W WATERS AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2716
Mailing Address - Country:US
Mailing Address - Phone:813-734-9218
Mailing Address - Fax:813-374-9221
Practice Address - Street 1:3550 W WATERS AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2716
Practice Address - Country:US
Practice Address - Phone:813-734-9218
Practice Address - Fax:813-374-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7342261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service