Basic Information
| Provider Information | |||||||||
| NPI: | 1992475263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525670188 | ||||||||
| FaxNumber: | 8133555101 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 TOWN CENTER BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335112906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133151500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2021 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | DELATORRE | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8137808440 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA MEDICAL CLINIC, LLC | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.