=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114064565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL FLORIDA HEALTH CLINICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2873 S DELANEY AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-843-8822
-----------------------------------------------------
Fax | 407-843-8826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2873 S DELANEY AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-843-8822
-----------------------------------------------------
Fax | 407-843-8826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. WENDY S PACKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-843-8822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | ME-75691
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------