Provider Demographics
NPI:1114605706
Name:SOLACE MEDICAL CARE PB LLC
Entity Type:Organization
Organization Name:SOLACE MEDICAL CARE PB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOS
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEZADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-301-8116
Mailing Address - Street 1:10524 MOSS PARK RD STE 204-750
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1890 PALM BAY RD NE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3071
Practice Address - Country:US
Practice Address - Phone:407-593-2290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-05
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty