Healthcare Provider Details

I. General information

NPI: 1972010346
Provider Name (Legal Business Name): PATH MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9119 MERRILL RD STE 32
JACKSONVILLE FL
32225-4306
US

IV. Provider business mailing address

6220 S ORANGE BLOSSOM TRL STE 200
ORLANDO FL
32809-4678
US

V. Phone/Fax

Practice location:
  • Phone: 904-575-3695
  • Fax: 855-831-2252
Mailing address:
  • Phone: 407-367-5160
  • Fax: 407-730-9928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberHCC11220
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberHCC11222
License Number StateFL

VIII. Authorized Official

Name: ANICIA O VICENTE
Title or Position: DIRECTOR OF BILLING
Credential: MA
Phone: 407-367-5166