1124051115 NPI number — HERON SPRINGS FAMILY MEDICINE INC

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 1124051115 NPI number — HERON SPRINGS FAMILY MEDICINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERON SPRINGS FAMILY MEDICINE INC
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124051115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8425 BALM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEEKI WACHEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34607-4419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-596-1770
Provider Business Mailing Address Fax Number:
352-596-1553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8425 BALM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEEKI WACHEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34607-4419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-596-1770
Provider Business Practice Location Address Fax Number:
352-596-1553
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKMAN
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
OWNER PARTNER
Authorized Official Telephone Number:
352-596-1770

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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