Provider Demographics
NPI:1801129119
Name:YOUR PLACE HEALTH SYSTEM LLC
Entity type:Organization
Organization Name:YOUR PLACE HEALTH SYSTEM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYDEL
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LEGRANDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:813-443-0866
Mailing Address - Street 1:1793 W HILLSBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1130
Mailing Address - Country:US
Mailing Address - Phone:813-443-0866
Mailing Address - Fax:813-225-1583
Practice Address - Street 1:1793 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1130
Practice Address - Country:US
Practice Address - Phone:813-443-0866
Practice Address - Fax:813-225-1583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCY926AOtherP-TAN
FLPENDINGMedicaid
D44801OtherUPIN #
D44801OtherUPIN #
FLPENDINGMedicaid