Provider Demographics
NPI:1730632225
Name:GOOD SAMARITAN CLINIC OF WEST VOLUSIA, INC.
Entity type:Organization
Organization Name:GOOD SAMARITAN CLINIC OF WEST VOLUSIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DR. LYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1386-738-6990
Mailing Address - Street 1:136 E PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-2871
Mailing Address - Country:US
Mailing Address - Phone:138-673-8699
Mailing Address - Fax:
Practice Address - Street 1:136 E PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2871
Practice Address - Country:US
Practice Address - Phone:138-673-8699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 694272251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care