Healthcare Provider Details

I. General information

NPI: 1578827473
Provider Name (Legal Business Name): KEITH W POLLACI CAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5664 SW 60TH AVE
OCALA FL
34474-5677
US

IV. Provider business mailing address

5664 SW 60TH AVE
OCALA FL
34474-5677
US

V. Phone/Fax

Practice location:
  • Phone: 352-291-5555
  • Fax: 352-291-9536
Mailing address:
  • Phone: 352-291-5555
  • Fax: 352-291-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAP4981
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: