Basic Information
| Provider Information | |||||||||
| NPI: | 1952423113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMA VISTA WALK-IN MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 784 E PRIMA VISTA BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349522271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728787311 | ||||||||
| FaxNumber: | 7728787321 | ||||||||
| Practice Location | |||||||||
| Address1: | 784 E PRIMA VISTA BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349522271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728787311 | ||||||||
| FaxNumber: | 7728787321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | MENDOZA | ||||||||
| AuthorizedOfficialFirstName: | SYLVIA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7728787311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 72956 | 01 | FL | GRP # FACILITY | OTHER |