Basic Information
| Provider Information | |||||||||
| NPI: | 1649329236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA DEPARTMENT OF HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA DEPARTMENT OF HEALTH IN ST LUCIE COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 NW MILNER DR | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349833392 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724623800 | ||||||||
| FaxNumber: | 7724623880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | SPERBER | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7724623800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA DEPARTMENT OF HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | FL | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 027966800 | 05 | FL | MEDICAID | 80-0575181 | 01 | FL | FEDERAL TAX ID | OTHER |