=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992014146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE CARDIOLOGY CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2010
-----------------------------------------------------
Last Update Date | 10/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 N CAUSEWAY SUITE C
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32169-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-424-8440
-----------------------------------------------------
Fax | 386-426-8839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 N CAUSEWAY SUITE C
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32169-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-424-8440
-----------------------------------------------------
Fax | 386-426-8839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. ERIC LUP-SING LO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 386-424-8440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME72993
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------