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General NPI Number Information
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NPI Number | 1962835686
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Entity Type | Organization
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Legal Business Name | DEVEREUX
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Dates
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Enumeration Date | 08/16/2013
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Last Update Date | 08/16/2013
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Provider Practice Location Address
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Address Line | 1010 EXECUTIVE CENTER DR
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City | ORLANDO
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State | FL
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Zip | 32803-3529
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Country | US
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Telephone | 407-367-1665
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Fax |
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Provider Business Mailing Address
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Address Line | 5850 T G LEE BLVD
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City | ORLANDO
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State | FL
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Zip | 32822-4407
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICIAN
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Name | VICKY HERRICK
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Credential | M.A.
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Telephone | 407-963-7873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State | FL
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