Provider Demographics
NPI:1902809122
Name:PRIMECARE AT TWIN LAKES LLC
Entity Type:Organization
Organization Name:PRIMECARE AT TWIN LAKES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DUVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-274-7800
Mailing Address - Street 1:1890 LPGA BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7130
Mailing Address - Country:US
Mailing Address - Phone:386-274-2212
Mailing Address - Fax:386-274-1508
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:STE 130
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7130
Practice Address - Country:US
Practice Address - Phone:386-274-2212
Practice Address - Fax:386-274-1508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47294261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB90F7OtherFLORIDA BLUE
FL77984OtherBC/BS OF FL PA GROUP
FLDC0901OtherRAILROAD MEDICARE GROUP
FLK5814Medicare PIN