Healthcare Provider Details

I. General information

NPI: 1104168095
Provider Name (Legal Business Name): LOW T CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12889 EMERALD COAST PKWY W SUITE 107B
MIRAMAR BEACH FL
32550-3243
US

IV. Provider business mailing address

622 MOUNTAIN DR
DESTIN FL
32541-2429
US

V. Phone/Fax

Practice location:
  • Phone: 850-830-3012
  • Fax:
Mailing address:
  • Phone: 850-830-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberME95148
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberME95148
License Number StateFL

VIII. Authorized Official

Name: DR. RICHARD CHERN
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 850-830-3012