Healthcare Provider Details

I. General information

NPI: 1669813135
Provider Name (Legal Business Name): LITTLE ANGEL SILVER STAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 S KIRKMAN RD
ORLANDO FL
32811-2891
US

IV. Provider business mailing address

4614 S KIRKMAN RD
ORLANDO FL
32811-2891
US

V. Phone/Fax

Practice location:
  • Phone: 407-512-5700
  • Fax: 800-752-1493
Mailing address:
  • Phone: 407-512-5700
  • Fax: 800-752-1493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberME44739
License Number StateFL

VIII. Authorized Official

Name: DR. MICAHEL J KERKES
Title or Position: STAFF DOCTOR
Credential: M.D
Phone: 407-512-5700