Healthcare Provider Details

I. General information

NPI: 1518848969
Provider Name (Legal Business Name): CICATRIX OF WINTER PARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 ORANGE AVE STE D1
WINTER PARK FL
32789-4946
US

IV. Provider business mailing address

1270 ORANGE AVE STE D1
WINTER PARK FL
32789-4946
US

V. Phone/Fax

Practice location:
  • Phone: 407-587-5559
  • Fax:
Mailing address:
  • Phone: 407-587-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEREMY PAUL EWBANK
Title or Position: OWNER
Credential:
Phone: 407-449-2645