=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952738049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTREACH COMMUNITY CARE NETWORK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2013
-----------------------------------------------------
Last Update Date | 02/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 N FREDERICK AVE SUITE D
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-255-5569
-----------------------------------------------------
Fax | 386-257-1245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 N FREDERICK AVE SUITE D
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-255-5569
-----------------------------------------------------
Fax | 386-257-1245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | LORETTA JENNINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-255-5569
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 12473
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------