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General NPI Number Information
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NPI Number | 1023450012
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Entity Type | Organization
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Legal Business Name | SOUTHEAST OUTPATIENT CONSULTANTS LLC
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Dates
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Enumeration Date | 07/19/2013
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Last Update Date | 07/19/2013
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Provider Practice Location Address
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Address Line | 1465 KINGSLEY AVE 1201
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City | ORANGE PARK
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State | FL
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Zip | 32073-4504
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Country | US
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Telephone | 904-421-2119
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Fax |
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Provider Business Mailing Address
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Address Line | 1665 KINGSLEY AVE SUITE 105
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City | ORANGE PARK
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State | FL
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Zip | 32073-4490
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | DEEVID MILLER
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Credential |
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Telephone | 904-421-2119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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