Healthcare Provider Details

I. General information

NPI: 1205128642
Provider Name (Legal Business Name): PRIMECARE LAKE NONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10437 MOSS PARK RD
ORLANDO FL
32832-5812
US

IV. Provider business mailing address

222 BROADWAY SUITE 302
KISSIMMEE FL
34741
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-8180
  • Fax: 407-347-4858
Mailing address:
  • Phone: 407-846-8180
  • Fax: 407-347-4858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME36463
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JAIME DANIELS
Title or Position: CEO
Credential:
Phone: 407-846-8180