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General NPI Number Information
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NPI Number | 1215338025
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Entity Type | Organization
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Legal Business Name | EXPRESS CARE OF LAKE COUNTY LLC
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Dates
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Enumeration Date | 09/11/2014
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Last Update Date | 11/15/2016
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Provider Practice Location Address
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Address Line | 2020 NIGHTINGALE LN
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City | TAVARES
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State | FL
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Zip | 32778-4361
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Country | US
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Telephone | 352-742-1500
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Fax | 352-742-2530
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Provider Business Mailing Address
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Address Line | 2020 NIGHTINGALE LN
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City | TAVARES
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State | FL
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Zip | 32778-4361
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Country | US
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Telephone | 352-742-1500
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Fax | 352-742-2530
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | KIMBERLY T JACKSON
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Credential | DO
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Telephone | 352-742-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS11411
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License Number State | FL
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