Provider Demographics
NPI:1053869487
Name:MEDICAL VENTURES OF AMERICA
Entity type:Organization
Organization Name:MEDICAL VENTURES OF AMERICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-315-1651
Mailing Address - Street 1:16890 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6705
Mailing Address - Country:US
Mailing Address - Phone:352-315-1651
Mailing Address - Fax:352-315-1703
Practice Address - Street 1:16890 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6705
Practice Address - Country:US
Practice Address - Phone:352-315-1651
Practice Address - Fax:352-315-1703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE REGIONAL URGENT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-14
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77919173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010331500Medicaid
FL010331500Medicaid