Organization
MEDICAL PAVILION CLINC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID S BALLESTAS (DOCTOR - OWNER)
(941) 629-9190
Entity
Organization
Contact information
Practice address
2525 HARBOR BLVD, SUITE 102, PORT CHARLOTTE, FL 33952-5317
(941) 629-9190
(941) 625-2751
Mailing address
2525 HARBOR BLVD, SUITE 102, PORT CHARLOTTE, FL 33952-5317
(941) 629-9190
(941) 625-2751
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
ME0044391
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0608916500
—
FL
Enumeration date
06/09/2008
Last updated
06/09/2008
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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