Provider Demographics
NPI:1679810972
Name:POLK CORRECTIONAL INSTITUTION
Entity type:Organization
Organization Name:POLK CORRECTIONAL INSTITUTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LONG
Authorized Official - Middle Name:N
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-984-2273
Mailing Address - Street 1:1531 MCCREA DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-3583
Mailing Address - Country:US
Mailing Address - Phone:863-984-2273
Mailing Address - Fax:863-984-1021
Practice Address - Street 1:10800 EVANS RD
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:FL
Practice Address - Zip Code:33868-6925
Practice Address - Country:US
Practice Address - Phone:863-984-2273
Practice Address - Fax:863-984-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100731302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization