MEDICARE: JOGI WALK-IN CLINIC INC

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	208D00000X	General Practice Physician		FL

General Provider Information

NPI Number	:	1629027008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOGI WALK-IN CLINIC INC

Provider Business Mailing Address
First Line	:	1500 LAKELAND HILLS BLVD
Second Line	:	SUITE #3
City	:	LAKELAND
State	:	FL
Zip	:	33805-3257
Country	:	US
Telephone Number	:	863-682-8200
Fax Number	:	863-687-4161

Provider Business Practice Location Address
First Line	:	1500 LAKELAND HILLS BLVD
Second Line	:	SUITE #3
City	:	LAKELAND
State	:	FL
Zip	:	33805-3257
Country	:	US
Telephone Number	:	863-682-8200
Fax Number	:	863-687-4161

Authorized Official
Title or Position	:	OWNER
Name	:	SUGUNA KUMARI MANGILIPUDI
Credential	:	OWNER
Telephone Number	:	863-682-8200

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	01/21/2014

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