=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730729229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LE CLINIC FAMILY CARE AND SPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2020
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 906 13TH ST
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34769-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-593-0145
-----------------------------------------------------
Fax | 407-593-0145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 906 13TH ST
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34769-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-593-0145
-----------------------------------------------------
Fax | 407-593-0145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN
-----------------------------------------------------
Name | ELBA L FERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-798-1176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------