1104072594 NPI number — PRIMECARE AT TWIN LAKES LLC

Table of content: (NPI 1104072594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104072594 NPI number — PRIMECARE AT TWIN LAKES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMECARE AT TWIN LAKES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRIMECARE URGENT CARE CENTERS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104072594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1890 LPGA BLVD
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32117-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-274-2212
Provider Business Mailing Address Fax Number:
386-274-1508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1327 SAXON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW SMYRNA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32169-3160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-767-2402
Provider Business Practice Location Address Fax Number:
386-767-1566
Provider Enumeration Date:
08/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEHMAN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-274-2212

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  10698 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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