=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295488492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FSF ORLANDO MSO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2022
-----------------------------------------------------
Last Update Date | 01/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3361 ROUSE RD STE 205
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-704-1150
-----------------------------------------------------
Fax | 407-286-6206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3361 ROUSE RD STE 205
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-704-1150
-----------------------------------------------------
Fax | 407-286-6206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | MRS. SHANA SIMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-704-1150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------