Healthcare Provider Details

I. General information

NPI: 1225082332
Provider Name (Legal Business Name): THREE RIVERS MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 SUWANNEE AVE NW
BRANFORD FL
32008-3265
US

IV. Provider business mailing address

208 SUWANNEE AVE NW
BRANFORD FL
32008-3265
US

V. Phone/Fax

Practice location:
  • Phone: 386-935-1607
  • Fax: 386-935-1667
Mailing address:
  • Phone: 386-935-1607
  • Fax: 386-935-1667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. FRANCES F COLE
Title or Position: ADMINISTRATOR
Credential: BA
Phone: 386-935-1607