=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063975175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR CENTER OF AMERICA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2019
-----------------------------------------------------
Last Update Date | 04/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 NW HALL OF FAME DR
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-4833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-335-5025
-----------------------------------------------------
Fax | 856-213-9269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 N ROUTE 73 STE A6
-----------------------------------------------------
City | WEST BERLIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08091-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-335-5025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | JAMES O'DARE III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-335-5025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------