=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962607416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAFFRAY PODIATRY CENTER PL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 09/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18940 DALE MABRY HWY N SUITE 101
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33548-4906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-949-7555
-----------------------------------------------------
Fax | 813-949-7554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 340683
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33694-0683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-949-7555
-----------------------------------------------------
Fax | 813-949-7554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KEVIN A JAFFRAY
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 813-949-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | P02662
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------