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1418 Bloomingdale Ave Valrico FL 33596-6110 | |
| (181) 325-2017 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 1418 Bloomingdale Ave, Valrico, Florida |
| Authorized Official Name and Position | Louisana Louis (OWNER) |
| Authorized Official Contact | 8139677075 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
10013 Water Works Ln Riverview FL 33578-5304 Ph: (813) 967-7075 | 1418 Bloomingdale Ave Valrico FL 33596-6110 Ph: (181) 325-2017 |
| NPI Number | 1811650831 |
|---|---|
| Provider Enumeration Date | 10/17/2021 |
| Last Update Date | 01/24/2024 |
| Certification Date | 01/24/2024 |
| Medicare PECOS PAC ID | 5395122279 |
|---|---|
| Medicare Enrollment ID | O20220516000085 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811650831 | NPI | - | NPPES |
| APRN11016727 | Other | FL | FLORIDA APRN LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Dov Rapoport |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1376971176 PECOS PAC ID: 3072421999 Enrollment ID: I20140407000431 |
| Provider Name | Elena Marie Eldridge |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1588938989 PECOS PAC ID: 3779815485 Enrollment ID: I20191030001430 |
| Provider Name | Louisana Louis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1588321665 PECOS PAC ID: 5991198947 Enrollment ID: I20220516001163 |
| Provider Name | Shameeka Gray |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194388967 PECOS PAC ID: 7012315666 Enrollment ID: I20230417000259 |
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