Healthcare Provider Details

I. General information

NPI: 1902809122
Provider Name (Legal Business Name): PRIMECARE AT TWIN LAKES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 LPGA BLVD STE 130
DAYTONA BEACH FL
32117-7130
US

IV. Provider business mailing address

1890 LPGA BLVD SUITE 130
DAYTONA BEACH FL
32117-7130
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-2212
  • Fax: 386-274-1508
Mailing address:
  • Phone: 386-274-2212
  • Fax: 386-274-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberME47294
License Number StateFL

VIII. Authorized Official

Name: CHARLES DUVA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-274-7800