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General NPI Number Information
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NPI Number | 1225247810
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE FAMILY PRACTICE PA
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 09/29/2011
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Provider Practice Location Address
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Address Line | 308 KINGSLEY LAKE DR STE 802
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-3046
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Country | US
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Telephone | 904-827-0788
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Fax |
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Provider Business Mailing Address
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Address Line | 308 KINGSLEY LAKE DR STE 802
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-3046
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Country | US
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Telephone | 904-827-0788
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MALGORZATA KALUZA
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Credential | MD
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Telephone | 904-827-0788
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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 | ME79394
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License Number State | FL
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