MEDICARE: TOWN CENTER FAMILY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	ME61253	FL
2	207Q00000X	Family Medicine Physician	ME61253	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y81BD	OTHER	FL	FL BLUE

General Provider Information

NPI Number	:	1396918579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOWN CENTER FAMILY CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 3123
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32085-3123
Country	:	US
Telephone Number	:	904-824-4990
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 HOSPITAL DR
Second Line	:	STE 290
City	:	PALM COAST
State	:	FL
Zip	:	32164-2380
Country	:	US
Telephone Number	:	386-473-7977
Fax Number	:	386-437-7732

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONNETTE WILLIAMS
Credential	:	MD
Telephone Number	:	386-437-7977

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	03/07/2017

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