1912177577 NPI number — FAMILY MEDICAL CARE OF PALM COAST LLC

Table of content: (NPI 1912177577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912177577 NPI number — FAMILY MEDICAL CARE OF PALM COAST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CARE OF PALM COAST 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:
VICENCIO ANTONIO III
Provider Other Organization Name Type Code:
5
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:
1912177577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 354339
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:
32135-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-586-3466
Provider Business Mailing Address Fax Number:
386-586-3467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-586-3466
Provider Business Practice Location Address Fax Number:
386-586-3467
Provider Enumeration Date:
03/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VICENCIO
Authorized Official First Name:
ANTONIO
Authorized Official Middle Name:
SISON
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
386-586-3466

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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