Healthcare Provider Details

I. General information

NPI: 1700400397
Provider Name (Legal Business Name): JUDA MCLAREN PBT (ASCP)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2020
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W COLONIAL DR
ORLANDO FL
32804-7336
US

IV. Provider business mailing address

1015 W COLONIAL DR
ORLANDO FL
32804-7336
US

V. Phone/Fax

Practice location:
  • Phone: 689-333-5188
  • Fax:
Mailing address:
  • Phone: 689-333-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number22-0830
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: