Healthcare Provider Details

I. General information

NPI: 1013404979
Provider Name (Legal Business Name): JEFF O CARLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WESTHALL LN STE 207
MAITLAND FL
32751-7478
US

IV. Provider business mailing address

140 PINE ISLE DR
SANFORD FL
32773-7434
US

V. Phone/Fax

Practice location:
  • Phone: 407-636-3532
  • Fax:
Mailing address:
  • Phone: 407-463-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: