1902809122 NPI number — PRIMECARE AT TWIN LAKES LLC

Table of content: (NPI 1902809122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902809122 NPI number — PRIMECARE AT TWIN LAKES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMECARE AT TWIN LAKES 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:
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:
1902809122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1890 LPGA BLVD
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32117-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-274-2212
Provider Business Mailing Address Fax Number:
386-274-1508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1890 LPGA BLVD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32117-7130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-274-2212
Provider Business Practice Location Address Fax Number:
386-274-1508
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DUVA
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-274-7800

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  ME47294 , 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: B90F7 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 77984 . This is a "BC/BS OF FL PA GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DC0901 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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