MEDICARE: CARDIOCARE OF JACKSONVILLE 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	207RC0000X	Cardiovascular Disease Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780168682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOCARE OF JACKSONVILLE LLC

Provider Business Mailing Address
First Line	:	2136 AUTUMN COVE CIR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-3229
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2136 AUTUMN COVE CIR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-3229
Country	:	US
Telephone Number	:	904-388-3351
Fax Number	:	904-388-2138

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LUCIEN ABBOUD
Credential	:	MD
Telephone Number	:	904-388-3351

Provider Enumeration Date	:	09/18/2018
Last Update Date	:	09/18/2018

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