Healthcare Provider Details

I. General information

NPI: 1891359998
Provider Name (Legal Business Name): KIDS AND FAMILIES MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12086 FORT CAROLINE RD STE 404
JACKSONVILLE FL
32225-7640
US

IV. Provider business mailing address

12086 FORT CAROLINE RD STE 404
JACKSONVILLE FL
32225-7640
US

V. Phone/Fax

Practice location:
  • Phone: 904-300-6248
  • Fax:
Mailing address:
  • Phone: 904-747-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KIA MITCHELL
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 904-300-6248