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
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