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General NPI Number Information
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NPI Number | 1104981398
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE PRIMARY CARE PA
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Dates
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Enumeration Date | 12/27/2006
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Last Update Date | 11/14/2011
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Provider Practice Location Address
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Address Line | 6028 BENNETT RD
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5004
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Country | US
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Telephone | 904-737-6422
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Fax | 904-730-8144
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Provider Business Mailing Address
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Address Line | 6028 BENNETT ROAD
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City | JACKSONVILLE
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State | FL
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Zip | 32216
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Country | US
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Telephone | 904-737-6422
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Fax | 904-730-8144
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MRS. DENISE LYNN VILLAVICENCIO LAZO
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Credential | RN
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Telephone | 904-338-9500
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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 | ME0046485
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License Number State | FL
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