1366607335 NPI number — FAMILY CARE OF PALM COAST PA

Table of content: (NPI 1366607335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366607335 NPI number — FAMILY CARE OF PALM COAST PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CARE OF PALM COAST PA
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:
1366607335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4869 PALM COAST PKWY NW # 802
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:
32137-3661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-445-2003
Provider Business Mailing Address Fax Number:
386-445-7445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4869 PALM COAST PARKWAY NW 802
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-445-2003
Provider Business Practice Location Address Fax Number:
386-445-7445
Provider Enumeration Date:
07/18/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RABKIN
Authorized Official First Name:
MARINA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-445-2003

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  92879 , 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)

  • Identifier: U6363Z . This is a "MEDICARE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 273940200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".