Organization
PROVITA PHYSICIAN GROUP CORP
Active
Parent organization
PROVITA PHYSICIAN GROUP CORP
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVITA PHYSICIAN GROUP CORP
Authorized official
ILEANA DELGADO (OFFICE MANAGER)
(305) 878-9072
Entity
Organization
Contact information
Practice address
3157 N UNIVERSITY DR STE 103, HOLLYWOOD, FL 33024-2258
(954) 322-8985
(954) 322-8981
Mailing address
3157 N UNIVERSITY DR STE 103, HOLLYWOOD, FL 33024-2258
(954) 322-8985
(954) 322-8981
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15388808
CAQH
FL
01
—
APRN9243523
MEDICAL LICENSE
FL
Enumeration date
06/15/2022
Last updated
03/07/2023
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