Basic Information
| Provider Information | |||||||||
| NPI: | 1396732541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA DEPARTMENT OF HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA DEPARTMENT OF HEALTH IN POLK COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 GOLFVIEW AVE | ||||||||
| Address2: | ATTN: ACCOUNTS RECEIVABLES | ||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635197900 | ||||||||
| FaxNumber: | 8635197696 | ||||||||
| Practice Location | |||||||||
| Address1: | 3241 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338052266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634132620 | ||||||||
| FaxNumber: | 8634992612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JOY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8635197900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 027963300 | 05 | FL | MEDICAID |