Basic Information
| Provider Information | |||||||||
| NPI: | 1003167073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY CARE IN YOUR HOME LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 341 W MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327632205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863165439 | ||||||||
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| Practice Location | |||||||||
| Address1: | 341 W MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327632205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863165439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2012 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROKER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3863165439 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | ARNP3333802 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 305918900 | 05 | FL | MEDICAID |