Healthcare Provider Details

I. General information

NPI: 1336606383
Provider Name (Legal Business Name): INFUSION CENTER OF JACKSONVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE STE 302-303
JACKSONVILLE FL
32256-9680
US

IV. Provider business mailing address

1726 COLE BLVD STE 250
LAKEWOOD CO
80401-3262
US

V. Phone/Fax

Practice location:
  • Phone: 561-323-8987
  • Fax:
Mailing address:
  • Phone: 720-465-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUE ELLEN ROTTURA
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 561-323-8987