Healthcare Provider Details

I. General information

NPI: 1376682559
Provider Name (Legal Business Name): SPACE COAST ENDOCRINOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 EXECUTIVE LN SUITE 110
ROCKLEDGE FL
32955-8068
US

IV. Provider business mailing address

150 N SYKES CREEK PKWY SUITE 300
MERRITT ISLAND FL
32953-3488
US

V. Phone/Fax

Practice location:
  • Phone: 321-638-2075
  • Fax: 321-638-2234
Mailing address:
  • Phone: 321-449-4168
  • Fax: 321-449-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: SANDI LAROCHE
Title or Position: MSO CREDENTIALING COORDINATOR
Credential:
Phone: 321-449-4168