Healthcare Provider Details

I. General information

NPI: 1730377045
Provider Name (Legal Business Name): BRANFORD FAMILY MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 SUWANNEE AVE NW
BRANFORD FL
32008-3275
US

IV. Provider business mailing address

303 SUWANNEE AVE NW
BRANFORD FL
32008-3275
US

V. Phone/Fax

Practice location:
  • Phone: 386-935-1093
  • Fax: 386-935-3113
Mailing address:
  • Phone: 386-935-1093
  • Fax: 386-935-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0028682
License Number StateFL

VIII. Authorized Official

Name: MRS. VIRGINIA V SAMERA
Title or Position: PRESIDENT
Credential:
Phone: 386-935-1093