1114514809 NPI number — FAMILY CARE MEDICAL CENTER II LLC

Table of content: (NPI 1114514809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114514809 NPI number — FAMILY CARE MEDICAL CENTER II LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CARE MEDICAL CENTER II 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:
1114514809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 N MILLS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34266-8716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-491-2277
Provider Business Mailing Address Fax Number:
863-491-3077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
819 N MILLS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34266-8716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-491-2277
Provider Business Practice Location Address Fax Number:
863-491-3077
Provider Enumeration Date:
12/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CETIN
Authorized Official First Name:
KENAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
863-491-2277

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 109045400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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