1700281821 NPI number — ALL FAMILY CLINIC OF DAYTONA BEACH, INC

Table of content: (NPI 1700281821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700281821 NPI number — ALL FAMILY CLINIC OF DAYTONA BEACH, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALL FAMILY CLINIC OF DAYTONA BEACH, 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:
FLORIDA MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1700281821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 MASON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32117-4612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-248-0107
Provider Business Mailing Address Fax Number:
386-248-0109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
697 MAITLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 1002
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32701-6821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-539-2111
Provider Business Practice Location Address Fax Number:
407-539-1211
Provider Enumeration Date:
10/31/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALVAREZ
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
SEVERINO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-248-0107

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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