Basic Information
| Provider Information | |||||||||
| NPI: | 1760705602 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOLANTIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8711 PERIMETER PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322166388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042232330 | ||||||||
| FaxNumber: | 9044254356 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 E COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328035217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213190212 | ||||||||
| FaxNumber: | 3213190213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2010 | ||||||||
| LastUpdateDate: | 03/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | BOWLING | ||||||||
| AuthorizedOfficialFirstName: | KAREB | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9042232330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | HCC8273 | FL | Y | Suppliers | Pharmacy |
No ID Information.