Basic Information
| Provider Information | |||||||||
| NPI: | 1063570364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA MEDICAL CLINIC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA MEDICAL CLINIC EYE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135284975 | ||||||||
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| Practice Location | |||||||||
| Address1: | 38101 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137825587 | ||||||||
| FaxNumber: | 8133555049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | DELATORRE | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8137808440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA MEDICAL CLINIC LLC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | DO2350 | FL | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 621212300 | 05 | FL | MEDICAID |