Basic Information
| Provider Information | |||||||||
| NPI: | 1255668620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL FLORIDA FAMILY HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5730 LAKE UNDERHILL RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328074366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079564320 | ||||||||
| FaxNumber: | 4079564337 | ||||||||
| Practice Location | |||||||||
| Address1: | 5730 LAKE UNDERHILL RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328074366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079564320 | ||||||||
| FaxNumber: | 4079564337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CMO | ||||||||
| AuthorizedOfficialTelephone: | 4073228645 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 029551508 | 05 | FL | MEDICAID |