Healthcare Provider Details

I. General information

NPI: 1851575377
Provider Name (Legal Business Name): FAMILY HEALTH CENTER AT PORT ST JOHN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 CURTIS BLVD SUITE 108
COCOA FL
32927-3962
US

IV. Provider business mailing address

3740 CURTIS BLVD SUITE 108
COCOA FL
32927-3962
US

V. Phone/Fax

Practice location:
  • Phone: 321-633-5500
  • Fax: 321-633-5566
Mailing address:
  • Phone: 321-633-5500
  • Fax: 321-633-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9694
License Number StateFL

VIII. Authorized Official

Name: DR. JANIS G BLACK
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 321-633-5500