MEDICARE: KD MEDICAL CHOICE 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	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10D2137145	OTHER	FL	CLIA ID

General Provider Information

NPI Number	:	1932769759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KD MEDICAL CHOICE LLC

Provider Business Mailing Address
First Line	:	1060 WILLA SPRINGS DR
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5214
Country	:	US
Telephone Number	:	407-604-1620
Fax Number	:

Provider Business Practice Location Address
First Line	:	1060 WILLA SPRINGS DR
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5214
Country	:	US
Telephone Number	:	407-604-1620
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. NAGI YOUSSEF
Credential	:
Telephone Number	:	407-604-1620

Provider Enumeration Date	:	06/14/2019
Last Update Date	:	06/14/2019

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