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General NPI Number Information
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NPI Number | 1114424280
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Entity Type | Organization
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Legal Business Name | CHILDREN'S EXPRESS CARE CLINIC
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Dates
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Enumeration Date | 04/06/2018
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Last Update Date | 07/31/2018
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Provider Practice Location Address
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Address Line | 10175 FORTUNE PARKWAY SUITE 402
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City | JACKSONVILLE
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State | FL
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Zip | 32256
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Country | US
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Telephone | 904-519-0008
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Fax | 904-379-7312
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Provider Business Mailing Address
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Address Line | 10175 FORTUNE PARKWAY SUITE 402
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City | JACKSONVILLE
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State | FL
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Zip | 32256-6750
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Country | US
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Telephone | 904-519-0008
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Fax | 904-379-7312
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Authorized Official
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Title or Position | PRESIDENT
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Name | SUWARNA TILAK
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Credential | MD
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Telephone | 904-519-0008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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