Organization
MYRTLE RIDGE PRIMARY CARE, P.A
Active
Organization subpart
No
Provider details
NPI number
Authorized official
YUDAISY MOGENA (OFFICE MANAGER)
(813) 909-7102
Entity
Organization
Contact information
Practice address
1539 DALE MABRY HWY STE 102, LUTZ, FL 33548-3008
(813) 909-7102
(813) 909-0199
Mailing address
1539 DALE MABRY HWY STE 102, LUTZ, FL 33548-3008
(813) 909-7102
(813) 909-0199
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
261QC1500X
Community Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
111603900
—
FL
Enumeration date
08/27/2021
Last updated
05/06/2024
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