1770313041 NPI number — FAMILY MEDICAL CLINIC LLC

Table of content: DR. THOMAS CHARLES FUGATE II M.D. (NPI 1639437361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770313041 NPI number — FAMILY MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CLINIC 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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1770313041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 73 BOX 4764
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NARANJITO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00719-9164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
939-232-7453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARRETERA 167 KM 10.9
Provider Second Line Business Practice Location Address:
BO DAJAOS
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
939-232-7453
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NIEVES LUCIANO
Authorized Official First Name:
GIL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
939-232-7453

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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