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1417 Hamlin Ave Unit G Saint Cloud FL 34771-8590 | |
| (407) 676-4276 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 1417 Hamlin Ave Unit G, Saint Cloud, Florida |
| Authorized Official Name and Position | Ekiba Ayisha Smith (OWNER) |
| Authorized Official Contact | 4076764276 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1427 Belladonna Pl # 1018 Saint Cloud FL 34771-5813 Ph: (954) 465-4942 | 1417 Hamlin Ave Unit G Saint Cloud FL 34771-8590 Ph: (407) 676-4276 |
| NPI Number | 1992573166 |
|---|---|
| Provider Enumeration Date | 12/18/2023 |
| Last Update Date | 12/13/2024 |
| Certification Date | 12/13/2024 |
| Medicare PECOS PAC ID | 6406387331 |
|---|---|
| Medicare Enrollment ID | O20241003000266 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1992573166 | NPI | - | NPPES |
| Provider Name | Precious Spencer |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235620527 PECOS PAC ID: 5890117287 Enrollment ID: I20200611001753 |
| Provider Name | Ivelisse Nieves |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1760979306 PECOS PAC ID: 8921548827 Enrollment ID: I20240905004694 |
| Provider Name | Alia Khederoo |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1922408939 PECOS PAC ID: 9032642400 Enrollment ID: I20241024001884 |
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