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General NPI Number Information
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NPI Number | 1093138760
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Entity Type | Organization
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Legal Business Name | STATE OF FLORIDA
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Dates
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Enumeration Date | 01/30/2014
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Last Update Date | 01/30/2014
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Provider Practice Location Address
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Address Line | 1217 N PEARL ST
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City | JACKSONVILLE
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State | FL
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Zip | 32202-3926
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Country | US
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Telephone | 904-791-1559
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Fax |
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Provider Business Mailing Address
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Address Line | 1217 N PEARL ST
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City | JACKSONVILLE
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State | FL
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Zip | 32202-3926
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Country | US
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Telephone | 904-791-1559
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. DEAN EDWARD WILLIS
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Credential | DRPH
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Telephone | 904-791-1559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | DI003429
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License Number State | FL
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