Healthcare Provider Details

I. General information

NPI: 1013005420
Provider Name (Legal Business Name): FAMILY PRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4699 N STATE ROAD 7 SUITE B-2
LAUDERDALE LAKES FL
33319-5879
US

IV. Provider business mailing address

4699 N STATE ROAD 7 SUITE B-2
LAUDERDALE LAKES FL
33319-5879
US

V. Phone/Fax

Practice location:
  • Phone: 954-486-1925
  • Fax: 954-486-1983
Mailing address:
  • Phone: 954-486-1925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME36462
License Number StateFL

VIII. Authorized Official

Name: GLENN S CHAPMAN
Title or Position: DIRECTOR
Credential: MD
Phone: 954-486-1925