1710716204 NPI number — SYNERGY MEDICAL WEIGHT LOSS AND WELLNESS, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710716204 NPI number — SYNERGY MEDICAL WEIGHT LOSS AND WELLNESS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNERGY MEDICAL WEIGHT LOSS AND WELLNESS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710716204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1803 WESTOVER RESERVE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDERMERE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34786-6213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-448-4482
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 PARK CENTER DR STE 2D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-5794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-961-9627
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2024

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-448-4482

Provider Taxonomy Codes

  • Taxonomy code: 207RB0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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