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620 S Lake St Ste 2 Leesburg FL 34748-6059 | |
| (352) 314-6589 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Multi-specialty |
| Location | 620 S Lake St Ste 2, Leesburg, Florida |
| Authorized Official Name and Position | David P Wagner (CHIEF FINANCIAL OFFICER) |
| Authorized Official Contact | 3212045222 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 491500 Leesburg FL 34749-1500 Ph: (352) 314-6589 | 620 S Lake St Ste 2 Leesburg FL 34748-6059 Ph: (352) 314-6589 |
| NPI Number | 1205571015 |
|---|---|
| Provider Enumeration Date | 05/05/2022 |
| Last Update Date | 02/03/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1205571015 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
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