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General NPI Number Information
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NPI Number | 1518848969
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Entity Type | Organization
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Legal Business Name | CICATRIX OF WINTER PARK LLC
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Dates
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Enumeration Date | 09/11/2025
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1270 ORANGE AVE STE D1
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City | WINTER PARK
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State | FL
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Zip | 32789-4946
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Country | US
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Telephone | 407-587-5559
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Fax |
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Provider Business Mailing Address
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Address Line | 1270 ORANGE AVE STE D1
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City | WINTER PARK
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State | FL
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Zip | 32789-4946
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Country | US
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Telephone | 407-587-5559
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEREMY PAUL EWBANK
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Credential |
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Telephone | 407-449-2645
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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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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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