Healthcare Provider Details

I. General information

NPI: 1710211289
Provider Name (Legal Business Name): CENTURY CLINICAL FAMILY MEDICINE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 LPGA BLVD STE. 140
DAYTONA BEACH FL
32117-5115
US

IV. Provider business mailing address

1410 LPGA BLVD STE. 140
DAYTONA BEACH FL
32117-5115
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-4750
  • Fax:
Mailing address:
  • Phone: 386-274-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9211084
License Number StateFL

VIII. Authorized Official

Name: MR. THOMAS L GASKIN JR.
Title or Position: CFO
Credential: CFP
Phone: 386-274-4750