1912177577 NPI number — FAMILY MEDICAL CARE OF PALM COAST LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912177577 NPI number — FAMILY MEDICAL CARE OF PALM COAST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CARE OF PALM COAST 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:
6
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:
1912177577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 354339
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32135-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-586-3466
Provider Business Mailing Address Fax Number:
386-586-3467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-586-3466
Provider Business Practice Location Address Fax Number:
386-586-3467
Provider Enumeration Date:
03/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VICENCIO
Authorized Official First Name:
ANTONIO
Authorized Official Middle Name:
SISON
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
386-586-3466

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)





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