MEDICARE: DELAND MEDICAL CENTER 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	207Q00000X	Family Medicine Physician	OS7148	FL

General Provider Information

NPI Number	:	1295275378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAND MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	320 S SPRING GARDEN AVE
Second Line	:	STE D
City	:	DELAND
State	:	FL
Zip	:	32720-5087
Country	:	US
Telephone Number	:	386-624-7977
Fax Number	:	386-873-4147

Provider Business Practice Location Address
First Line	:	320 S SPRING GARDEN AVE
Second Line	:	STE D
City	:	DELAND
State	:	FL
Zip	:	32720-5087
Country	:	US
Telephone Number	:	386-624-7977
Fax Number	:	386-873-4147

Authorized Official
Title or Position	:	D.O. MEDICAL DIRECTOR
Name	:	YVES M LAVENTURE
Credential	:	D.O.
Telephone Number	:	386-624-7977

Provider Enumeration Date	:	03/08/2017
Last Update Date	:	03/08/2017

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