Healthcare Provider Details

I. General information

NPI: 1023041001
Provider Name (Legal Business Name): LOGGERHEAD MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E NEW HAVEN AVE
MELBOURNE FL
32901-4576
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 321-729-8223
  • Fax: 321-729-6252
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME105112
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME51048
License Number StateFL

VIII. Authorized Official

Name: NANCY L LAYTON
Title or Position: OWNER
Credential: M.D.
Phone: 321-729-8223