Healthcare Provider Details

I. General information

NPI: 1376753632
Provider Name (Legal Business Name): MCLANE MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 GATEWAY CIR UNIT 6
JACKSONVILLE FL
32259-4085
US

IV. Provider business mailing address

140 GATEWAY CIR UNIT 6
JACKSONVILLE FL
32259-4085
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-1772
  • Fax: 904-825-1740
Mailing address:
  • Phone: 904-825-1772
  • Fax: 904-825-1740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberHCC6616
License Number StateFL

VIII. Authorized Official

Name: CHARLES E. MCLANE
Title or Position: PRESIDENT
Credential:
Phone: 904-825-1772