MEDICARE: JACKSONVILLE PRIMARY CARE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME0046485	FL

General Provider Information

NPI Number	:	1104981398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE PRIMARY CARE PA

Provider Business Mailing Address
First Line	:	6028 BENNETT ROAD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216
Country	:	US
Telephone Number	:	904-737-6422
Fax Number	:	904-730-8144

Provider Business Practice Location Address
First Line	:	6028 BENNETT RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5004
Country	:	US
Telephone Number	:	904-737-6422
Fax Number	:	904-730-8144

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MRS. DENISE LYNN VILLAVICENCIO LAZO
Credential	:	RN
Telephone Number	:	904-338-9500

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	11/14/2011

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