Healthcare Provider Details

I. General information

NPI: 1023210986
Provider Name (Legal Business Name): NORTH FL ARTHRITIS CLINIC, PA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4551 W EST US 90 SUITE 102
LAKE CITY FL
32055
US

IV. Provider business mailing address

4551 W EST US 90 SUITE 102
LAKE CITY FL
32055
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-6520
  • Fax: 386-719-6592
Mailing address:
  • Phone: 386-719-6520
  • Fax: 386-719-6592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME70903
License Number StateFL

VIII. Authorized Official

Name: MS. SUSANNE CICERO
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-719-6520