MEDICARE: PRIMECARE LAKE NONA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	207Q00000X	Family Medicine Physician	ME36463	FL

General Provider Information

NPI Number	:	1205128642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMECARE LAKE NONA, LLC

Provider Business Mailing Address
First Line	:	222 BROADWAY
Second Line	:	SUITE 302
City	:	KISSIMMEE
State	:	FL
Zip	:	34741
Country	:	US
Telephone Number	:	407-846-8180
Fax Number	:	407-347-4858

Provider Business Practice Location Address
First Line	:	10437 MOSS PARK RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-5812
Country	:	US
Telephone Number	:	407-846-8180
Fax Number	:	407-347-4858

Authorized Official
Title or Position	:	CEO
Name	:	MS. JAIME DANIELS
Credential	:
Telephone Number	:	407-846-8180

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	06/20/2018

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