=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154833887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZABETH DAQUILA MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 851 DUNLAWTON AVE STE 102
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-402-7827
-----------------------------------------------------
Fax | 386-410-5457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 851 DUNLAWTON AVE STE 102
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-402-7827
-----------------------------------------------------
Fax | 386-410-5457
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHEMA BURRILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-402-7827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME117878
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------