Organization
MOHIB MEDICAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARK NICOLE (MANAGER)
(321) 223-4470
Entity
Organization
Contact information
Practice address
410 LIONEL WAY STE 200, DAVENPORT, FL 33837-7809
(863) 353-2602
Mailing address
410 LIONEL WAY STE 200, DAVENPORT, FL 33837-7809
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
266607300
—
FL
01
—
ME105262
MEDICAL LICENSE
—
Enumeration date
05/22/2017
Last updated
05/22/2017
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