Healthcare Provider Details

I. General information

NPI: 1275163461
Provider Name (Legal Business Name): LCB PHYSICIANS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 03/01/2020
Certification Date: 03/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PALMETTO ST
NEW SMYRNA BEACH FL
32168-7323
US

IV. Provider business mailing address

1648 TAYLOR RD # 606
PORT ORANGE FL
32128-6753
US

V. Phone/Fax

Practice location:
  • Phone: 386-267-6224
  • Fax: 386-703-2304
Mailing address:
  • Phone: 813-313-8013
  • Fax: 386-703-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: LOUIS CHARLES BLAUM III
Title or Position: OWNER
Credential: MD
Phone: 813-313-8013