Individual
DEAISA ZHANE BOMORT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1836 N CRYSTAL LAKE DR, LAKELAND, FL 33801-6576
(863) 738-9493
Mailing address
1836 N CRYSTAL LAKE DR, LAKELAND, FL 33801-6576
(863) 738-9493
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
B563179949530
FL
Other
Enumeration date
08/02/2021
Last updated
08/02/2021
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