MEDICARE: KIDS AND FAMILIES MEDICAL CLINIC 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	2080P0205X	Pediatric Endocrinology Physician
2	207QA0000X	Adolescent Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1891359998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS AND FAMILIES MEDICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	12086 FORT CAROLINE RD STE 404
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7640
Country	:	US
Telephone Number	:	904-747-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	12086 FORT CAROLINE RD STE 404
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7640
Country	:	US
Telephone Number	:	904-300-6248
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DR. KIA MITCHELL
Credential	:	MD
Telephone Number	:	904-300-6248

Provider Enumeration Date	:	04/24/2019
Last Update Date	:	06/09/2020

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