Healthcare Provider Details

I. General information

NPI: 1710049671
Provider Name (Legal Business Name): THREE RIVERS MEDICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 02/04/2010
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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2934442
License Number StateFL

VIII. Authorized Official

Name: MS. PEGGY L MALONEY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 386-935-1607