Provider Demographics
NPI:1457772139
Name:NORTHEAST FLORIDA JOINT PRESERVATION AND CARTILAGE RESTORATION CENTER
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA JOINT PRESERVATION AND CARTILAGE RESTORATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LALLISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-308-7792
Mailing Address - Street 1:PO BOX 65201
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-0004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9560 CROSSHILL BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-5850
Practice Address - Country:US
Practice Address - Phone:904-308-7792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112470207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty