1477201622 NPI number — FLORIDA CLINICAL PRACTICE ASSOCIATION INC

Table of content: (NPI 1477201622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477201622 NPI number — FLORIDA CLINICAL PRACTICE ASSOCIATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA CLINICAL PRACTICE ASSOCIATION 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:
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:
1477201622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13833
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19101-3833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-265-7922
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4197 NW 86TH TER FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32606-9278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-265-4357
Provider Business Practice Location Address Fax Number:
352-627-4161
Provider Enumeration Date:
03/16/2022

Additional Information

Authorized Official

Authorized Official Last Name:
DEWAR
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
352-265-8309

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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