Healthcare Provider Details

I. General information

NPI: 1962226381
Provider Name (Legal Business Name): AVE MARIA PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 ANNUNCIATION CIR UNIT 103
AVE MARIA FL
34142-9655
US

IV. Provider business mailing address

5080 ANNUNCIATION CIR UNIT 103
AVE MARIA FL
34142-9655
US

V. Phone/Fax

Practice location:
  • Phone: 239-322-0917
  • Fax: 239-658-5143
Mailing address:
  • Phone: 239-322-0917
  • Fax: 239-658-5143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROLINA MENA
Title or Position: OFFICE MANAGER
Credential:
Phone: 239-322-0917