Basic Information
| Provider Information | |||||||||
| NPI: | 1215986872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA COMMUNITY HEALTH CENTERS INC | ||||||||
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| OtherOrganizationName: | PORT ST. LUCIE CHILDREN'S HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5618441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 SE HILLMOOR DR | ||||||||
| Address2: | SUITE 19 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349527552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723358455 | ||||||||
| FaxNumber: | 7723354959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | WILHELMINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5618449443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 684660202 | 05 | FL | MEDICAID | 684660203 | 05 | FL | MEDICAID |