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General NPI Number Information
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NPI Number | 1639636897
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Entity Type | Organization
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Legal Business Name | INFECTIOUS DISEASE OF LAKE COUNTY,LLC
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Dates
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Enumeration Date | 02/25/2019
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Last Update Date | 02/25/2019
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Provider Practice Location Address
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Address Line | 2050 CLASSIQUE LN
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City | TAVARES
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State | FL
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Zip | 32778-5787
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Country | US
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Telephone | 352-835-2391
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Fax |
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Provider Business Mailing Address
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Address Line | 2050 CLASSIQUE LN
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City | TAVARES
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State | FL
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Zip | 32778-5787
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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 | MANAGER
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Name | YULISA ASTUDILLO
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Credential | APRN
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Telephone | 352-835-2391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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