Healthcare Provider Details

I. General information

NPI: 1770553018
Provider Name (Legal Business Name): PEDIATRIC PRIMARY CARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 NE 22ND AVE SUITE A
OCALA FL
34470-4761
US

IV. Provider business mailing address

1539 NE 22ND AVE SUITE A
OCALA FL
34470-4761
US

V. Phone/Fax

Practice location:
  • Phone: 352-369-7800
  • Fax: 352-369-2141
Mailing address:
  • Phone: 352-369-7800
  • Fax: 352-369-2141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY E BAXLA
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 352-369-7835