Provider Demographics
NPI:1538418868
Name:FIRST COAST LTC, INC
Entity type:Organization
Organization Name:FIRST COAST LTC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-309-6504
Mailing Address - Street 1:6555 CHESTER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2279
Mailing Address - Country:US
Mailing Address - Phone:904-309-6504
Mailing Address - Fax:904-503-3577
Practice Address - Street 1:25 STATE ROAD 13
Practice Address - Street 2:ATT: CLINIC
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-2842
Practice Address - Country:US
Practice Address - Phone:904-309-6504
Practice Address - Fax:904-503-3577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRST COAST LTC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-31
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31637208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371340700Medicaid
CG-1814OtherRR MEDICARE
FL98411Medicare PIN