Provider Demographics
NPI:1548819741
Name:FLORIDA PRIMARY CARE AND SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:FLORIDA PRIMARY CARE AND SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-447-6615
Mailing Address - Street 1:6 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3808
Mailing Address - Country:US
Mailing Address - Phone:386-447-6615
Mailing Address - Fax:386-447-1266
Practice Address - Street 1:140 PINNACLES DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2322
Practice Address - Country:US
Practice Address - Phone:386-597-2829
Practice Address - Fax:386-313-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care