Healthcare Provider Details

I. General information

NPI: 1164192407
Provider Name (Legal Business Name): FLORIDA MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 BRANDON MAIN ST STE C
BRANDON FL
33511-5018
US

IV. Provider business mailing address

38135 MARKET SQ
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 813-973-1304
  • Fax:
Mailing address:
  • Phone: 352-567-0188
  • Fax: 813-355-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOE DELATORRE
Title or Position: CEO
Credential:
Phone: 813-780-8440