Basic Information
| Provider Information | |||||||||
| NPI: | 1144774969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSTAT WELLNESS LAKE COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4651 CHARLOTTE PARK DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045296161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1939 SALK AVE | ||||||||
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| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327784306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045296161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATTON | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | JOHNSON | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RISK MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 7049365546 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.