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General NPI Number Information
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NPI Number | 1770922007
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Entity Type | Organization
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Legal Business Name | NORTH LAGOON MEDICAL, LLC
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Dates
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Enumeration Date | 06/20/2013
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Last Update Date | 06/20/2013
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Provider Practice Location Address
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Address Line | 8317 FRONT BEACH RD STE 37B
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32407-4896
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Country | US
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Telephone | 352-504-8546
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Fax |
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Provider Business Mailing Address
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Address Line | 8317 FRONT BEACH RD
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32407-4885
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Country | US
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Telephone | 352-504-8546
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Fax |
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Authorized Official
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Title or Position | MGR
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Name | RONALD JOSEPH ALDRIDGE
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Credential | PA
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Telephone | 352-504-8546
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA3330
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License Number State | FL
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