Basic Information
| Provider Information | |||||||||
| NPI: | 1619463825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA MEDICAL CLINIC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA MEDICAL CLINIC ORTHO DISPENSING COMMERCIAL | ||||||||
| 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: | 602 S HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336062413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132532406 | ||||||||
| FaxNumber: | 8132514290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2018 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DELATORRE | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8137808440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA MEDICAL CLINIC LLC | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.