=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174588586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACARANDA FAMILY MEDICINE P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2006
-----------------------------------------------------
Last Update Date | 09/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4315 TAMIAMI TRL S
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34293-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-497-4303
-----------------------------------------------------
Fax | 941-497-3107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4315 TAMIAMI TRL S
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34293-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-497-4303
-----------------------------------------------------
Fax | 941-497-3107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN A. SOLLOTT
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 941-497-4303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------