Healthcare Provider Details

I. General information

NPI: 1548530736
Provider Name (Legal Business Name): CHILDREN'S EXPRESS CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 07/21/2022
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 COLLEGE DR UNIT 100-102
MIDDLEBURG FL
32068-8530
US

IV. Provider business mailing address

10175 FORTUNE PKWY UNIT 402
JACKSONVILLE FL
32256-6750
US

V. Phone/Fax

Practice location:
  • Phone: 904-644-8669
  • Fax:
Mailing address:
  • Phone: 904-519-0008
  • Fax: 904-379-7312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number604727
License Number StateFL

VIII. Authorized Official

Name: DR. SUWARNA M TILAK
Title or Position: PRESIDENT
Credential: MD
Phone: 904-519-0008