Healthcare Provider Details

I. General information

NPI: 1013146877
Provider Name (Legal Business Name): FCC COLEMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 NE 54TH TERRACE
COLEMAN FL
33521-1029
US

IV. Provider business mailing address

PO BOX 1029
COLEMAN FL
33521-1029
US

V. Phone/Fax

Practice location:
  • Phone: 352-689-3018
  • Fax:
Mailing address:
  • Phone: 352-689-3267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IVAN NEGRON
Title or Position: COMPLEX CLINICAL DIRECTOR
Credential: M.D.
Phone: 352-689-3018