=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811239460
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE INJURY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 672 N SEMORAN BLVD STE 101
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32807-3367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-0306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 672 N SEMORAN BLVD STE 101
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32807-3367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-0306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ALBERT E FORD
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 813-494-7277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 0S1653
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------