Healthcare Provider Details

I. General information

NPI: 1679402564
Provider Name (Legal Business Name): TILLMAN LEE EDDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E WEBSTER AVE
WINTER PARK FL
32789-3226
US

IV. Provider business mailing address

321 E WEBSTER AVE
WINTER PARK FL
32789-3226
US

V. Phone/Fax

Practice location:
  • Phone: 561-704-6246
  • Fax:
Mailing address:
  • Phone: 561-704-6246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: