Healthcare Provider Details

I. General information

NPI: 1477377026
Provider Name (Legal Business Name): UROLIFE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 SW PROFESSIONAL GLN
LAKE CITY FL
32025-1104
US

IV. Provider business mailing address

256 SW PROFESSIONAL GLN
LAKE CITY FL
32025-1104
US

V. Phone/Fax

Practice location:
  • Phone: 386-758-8937
  • Fax:
Mailing address:
  • Phone: 386-758-8937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARAH C DUMAS
Title or Position: MANAGER
Credential:
Phone: 386-758-8937