Provider Demographics
NPI:1225046626
Name:DAYTONA BEACH VA OUTPAITENT CLINIC
Entity Type:Organization
Organization Name:DAYTONA BEACH VA OUTPAITENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-323-7542
Mailing Address - Street 1:6810 PLUMPJACK CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4083
Mailing Address - Country:US
Mailing Address - Phone:386-233-9774
Mailing Address - Fax:
Practice Address - Street 1:551 NATIONAL HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1495
Practice Address - Country:US
Practice Address - Phone:386-323-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88745261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center