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General NPI Number Information
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NPI Number | 1396259735
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Entity Type | Organization
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Legal Business Name | FREEDOM HEALTH AND WELLNESS OF LAKE CITY, LLC
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Dates
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Enumeration Date | 11/21/2017
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Last Update Date | 03/08/2018
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Provider Practice Location Address
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Address Line | 263 SW PROFESSIONAL GLN
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City | LAKE CITY
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State | FL
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Zip | 32025-1105
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Country | US
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Telephone | 386-623-0850
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Fax |
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Provider Business Mailing Address
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Address Line | 263 SW PROFESSIONAL GLN
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City | LAKE CITY
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State | FL
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Zip | 32025-1105
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Country | US
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Telephone | 386-623-0850
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MISTY HERNDON
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Credential |
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Telephone | 386-623-0850
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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 |
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License Number State |
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