Healthcare Provider Details

I. General information

NPI: 1962464248
Provider Name (Legal Business Name): FAMILY HEALTH CENTER OF COLUMBIA COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 NW ALBRITTON LN
LAKE CITY FL
32055-0249
US

IV. Provider business mailing address

PO BOX 249
LAKE CITY FL
32056-0249
US

V. Phone/Fax

Practice location:
  • Phone: 386-758-5552
  • Fax: 386-752-9143
Mailing address:
  • Phone: 386-758-5552
  • Fax: 386-752-9143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME92183
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number5080000065
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0003548
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101298
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1181972
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP2908802
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN T MYLES
Title or Position: CEO
Credential:
Phone: 386-758-5552