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General NPI Number Information
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NPI Number | 1205128642
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Entity Type | Organization
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Legal Business Name | PRIMECARE LAKE NONA, LLC
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Dates
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Enumeration Date | 05/04/2011
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 10437 MOSS PARK RD
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City | ORLANDO
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State | FL
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Zip | 32832-5812
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Country | US
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Telephone | 407-846-8180
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Fax | 407-347-4858
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Provider Business Mailing Address
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Address Line | 222 BROADWAY SUITE 302
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City | KISSIMMEE
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State | FL
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Zip | 34741
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Country | US
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Telephone | 407-846-8180
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Fax | 407-347-4858
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Authorized Official
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Title or Position | CEO
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Name | MS. JAIME DANIELS
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Credential |
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Telephone | 407-846-8180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME36463
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License Number State | FL
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