Basic Information
| Provider Information | |||||||||
| NPI: | 1578937140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA MEDICAL CLINIC LLC | ||||||||
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| OtherOrganizationName: | FLORIDA MEDICAL CLINIC EYE CENTER TPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 13602 N 46TH ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139724444 | ||||||||
| FaxNumber: | 8139791600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | DELATORRE | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8137808774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA MEDICAL CLINIC LLC | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | DO5641 | FL | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.