Healthcare Provider Details

I. General information

NPI: 1790047934
Provider Name (Legal Business Name): TOWN CENTER FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 SYCAMORE ST SUITE 130
CELEBRATION FL
34747-4995
US

IV. Provider business mailing address

610 SYCAMORE ST SUITE 130
CELEBRATION FL
34747-4995
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-6616
  • Fax:
Mailing address:
  • Phone: 386-788-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberME100993
License Number StateFL

VIII. Authorized Official

Name: CHAD BLACK
Title or Position: OWNER/PARTNER
Credential:
Phone: 386-788-6616