MEDICARE: FAMILY CARE CENTER, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1689441255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	2860 S CIRCLE DR STE 109
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4195
Country	:	US
Telephone Number	:	719-540-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 W CYPRESS ST STE 825
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-4253
Country	:	US
Telephone Number	:	719-540-2100
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER ENGAGEMENT & CREDENTIALING
Name	:	CHRISTIAN M ELLIS
Credential	:
Telephone Number	:	765-540-2100

Provider Enumeration Date	:	12/05/2023
Last Update Date	:	12/05/2023

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