=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346045739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAULORICO MCFADDEN HOLDING CO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2025
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3234 S FLORIDA AVE STE F
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-619-9740
-----------------------------------------------------
Fax | 863-644-4178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3234 S FLORIDA AVE STE F
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-619-9740
-----------------------------------------------------
Fax | 863-644-4178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. KATRINA DAVIS HICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-619-9740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------