Basic Information
| Provider Information | |||||||||
| NPI: | 1629670369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY CARE PARTNERS OF NORTHEAST FLORIDA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6520 FORT CAROLINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322772044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047453618 | ||||||||
| FaxNumber: | 9047224271 | ||||||||
| Practice Location | |||||||||
| Address1: | 4565 US HIGHWAY 17 STE 106 | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042694559 | ||||||||
| FaxNumber: | 9042694597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARRIERE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9047447300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY CARE PARTNERS OF NORTHEAST FLORIDA, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.