Provider Demographics
NPI:1235422775
Name:MD2U FLORIDA LLC
Entity Type:Organization
Organization Name:MD2U FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/CIO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-416-1851
Mailing Address - Street 1:PO BOX 7219
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40257-0219
Mailing Address - Country:US
Mailing Address - Phone:502-416-1851
Mailing Address - Fax:502-416-1857
Practice Address - Street 1:10151 DEERWOOD PARK BLVD
Practice Address - Street 2:200-250
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0566
Practice Address - Country:US
Practice Address - Phone:502-327-9100
Practice Address - Fax:502-742-3767
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MD2U MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-17
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2045820OtherCLIA - CERTIFICATE OF WAIVER