Basic Information
| Provider Information | |||||||||
| NPI: | 1588697502 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE BARRANCO CLINIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E LAKE HOWARD DR | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338813155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632991251 | ||||||||
| FaxNumber: | 8632997666 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E LAKE HOWARD DR | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338813155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632991251 | ||||||||
| FaxNumber: | 8632997666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | LYLE | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8632991251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 2530082-00 | 05 | FL | MEDICAID |