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General NPI Number Information
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NPI Number | 1316217896
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Entity Type | Organization
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Legal Business Name | FLORIDA CENTER FOR INFECTIOUS DISEASES, INC.
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Dates
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Enumeration Date | 12/30/2011
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Last Update Date | 02/16/2012
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Provider Practice Location Address
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Address Line | 14810 OLD SAINT AUGUSTINE RD SUITE 201
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City | JACKSONVILLE
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State | FL
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Zip | 32258-2451
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Country | US
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Telephone | 904-292-0863
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Fax | 904-212-0884
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Provider Business Mailing Address
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Address Line | 5055 MONROE FOREST DR
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City | JACKSONVILLE
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State | FL
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Zip | 32257-2204
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DESIREE D CLARK
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Credential | PA-C
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Telephone | 904-322-1140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME96311
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License Number State | FL
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