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General NPI Number Information
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NPI Number | 1770092231
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Entity Type | Organization
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Legal Business Name | CANTRELL CORNERSTONE CLINIC, LLC
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Dates
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Enumeration Date | 09/27/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 11512 LAKE MEAD AVE UNIT 302
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City | JACKSONVILLE
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State | FL
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Zip | 32256-9685
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Country | US
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Telephone | 904-900-3472
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Fax | 904-503-2373
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Provider Business Mailing Address
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Address Line | 11512 LAKE MEAD AVE UNIT 302
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City | JACKSONVILLE
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State | FL
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Zip | 32256-9685
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Country | US
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Telephone | 904-900-3472
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Fax | 904-503-2373
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Authorized Official
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Title or Position | OWNER
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Name | AMMALA CANTRELL
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Credential | MD
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Telephone | 904-673-5553
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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 | ME84833
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License Number State | FL
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