Provider Demographics
NPI:1285685370
Name:PCCC OF VOLUSIA LLC
Entity Type:Organization
Organization Name:PCCC OF VOLUSIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:AILANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-423-0505
Mailing Address - Street 1:1055 N DIXIE FWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6201
Mailing Address - Country:US
Mailing Address - Phone:386-423-0505
Mailing Address - Fax:386-423-0515
Practice Address - Street 1:1055 N DIXIE FWY
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6201
Practice Address - Country:US
Practice Address - Phone:386-423-0505
Practice Address - Fax:386-423-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89115207RC0200X, 207RP1001X
207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID