Healthcare Provider Details

I. General information

NPI: 1790839678
Provider Name (Legal Business Name): NORTH FLORIDA MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E MAIN ST
LAKE BUTLER FL
32054-1352
US

IV. Provider business mailing address

655 E MAIN ST
LAKE BUTLER FL
32054-1352
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-3656
  • Fax:
Mailing address:
  • Phone: 386-496-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number576
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number32011614
License Number StateFL

VIII. Authorized Official

Name: SALVADOR ANTONIO PEREZ
Title or Position: PRESIDENT
Credential:
Phone: 386-496-1575