Basic Information
| Provider Information | |||||||||
| NPI: | 1568425809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQUARE | ||||||||
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| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137801255 | ||||||||
| FaxNumber: | 8137809773 | ||||||||
| Practice Location | |||||||||
| Address1: | 17401 COMMERCE PARK BLVD STE 107 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336473507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137828311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | DELATORRE | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8137808440 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA MEDICAL CLINIC , LLC | ||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 800006196 | FL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 690006221 | 01 | FL | RR MEDICARE | OTHER |