Healthcare Provider Details

I. General information

NPI: 1467621151
Provider Name (Legal Business Name): CAROLYN D PASS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 DRUID CIR
LAKE WALES FL
33853-4339
US

IV. Provider business mailing address

1105 DRUID CIR
LAKE WALES FL
33853-4339
US

V. Phone/Fax

Practice location:
  • Phone: 863-676-8237
  • Fax: 863-676-8207
Mailing address:
  • Phone: 863-676-8237
  • Fax: 863-676-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME73921
License Number StateFL

VIII. Authorized Official

Name: MS. CAROLYN D PASS
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 863-676-8237