Healthcare Provider Details

I. General information

NPI: 1225046626
Provider Name (Legal Business Name): DAYTONA BEACH VA OUTPAITENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

IV. Provider business mailing address

6810 PLUMPJACK CT
PORT ORANGE FL
32128-4083
US

V. Phone/Fax

Practice location:
  • Phone: 386-323-7500
  • Fax:
Mailing address:
  • Phone: 386-233-9774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME 88745
License Number StateFL

VIII. Authorized Official

Name: DR. ROGER H. BOWER
Title or Position: CHIEF MEDICAL OFFICER
Credential:
Phone: 386-323-7542