Provider Demographics
NPI:1669652681
Name:SENIOR HEALTH CARE OF VOLUSIA
Entity Type:Organization
Organization Name:SENIOR HEALTH CARE OF VOLUSIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-257-1626
Mailing Address - Street 1:405 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2730
Mailing Address - Country:US
Mailing Address - Phone:386-257-1626
Mailing Address - Fax:386-254-7507
Practice Address - Street 1:405 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2730
Practice Address - Country:US
Practice Address - Phone:386-257-1626
Practice Address - Fax:386-254-7507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2204Medicare PIN