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General NPI Number Information
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NPI Number | 1053384610
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Entity Type | Organization
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Legal Business Name | EAST VOLUSIA FAMILY PRACTICE PA
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Dates
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Enumeration Date | 02/13/2006
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Last Update Date | 07/09/2008
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Provider Practice Location Address
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Address Line | 3911 S NOVA RD
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City | PORT ORANGE
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State | FL
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Zip | 32127-4910
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Country | US
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Telephone | 386-322-0811
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Fax | 386-761-5449
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Provider Business Mailing Address
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Address Line | 3911 S NOVA RD
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City | PORT ORANGE
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State | FL
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Zip | 32127-4910
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Country | US
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Telephone | 386-322-0811
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Fax | 386-761-5449
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LANE E JENNINGS
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Credential | M.D.
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Telephone | 386-322-0811
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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