# AVITA MEDICAL CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1992302574
- **Authorized official:** JENNY M SEGARRA (PRESIDENT)
- **Authorized official phone:** (813) 330-2737

## Contact information

- **Practice address:** 14831 N FLORIDA AVE, TAMPA, FL 33613-1825
- **Practice address phone:** (813) 330-2737
- **Practice address fax:** (813) 210-9205
- **Mailing address:** 14831 N FLORIDA AVE, TAMPA, FL 33613-1825
- **Mailing address phone:** (813) 210-0982
- **Mailing address fax:** (813) 210-9205

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |
| 225100000X | Physical Therapist | — | — | — |
| 225X00000X | Occupational Therapist | — | — | — |

## Other

- **Enumeration date:** 10/06/2020
- **Last updated:** 09/02/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 109041600 | — | FL |