Healthcare Provider Details

I. General information

NPI: 1831615087
Provider Name (Legal Business Name): PRIMARY CARE OF ORANGE CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2017
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E MINNESOTA AVE
ORANGE CITY FL
32763-2312
US

IV. Provider business mailing address

341 W MINNESOTA AVE
ORANGE CITY FL
32763-2205
US

V. Phone/Fax

Practice location:
  • Phone: 386-241-0274
  • Fax: 386-241-0275
Mailing address:
  • Phone: 386-473-3553
  • Fax: 888-509-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberARNP3333802
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHN CROKER
Title or Position: OWNER
Credential: APRN
Phone: 386-473-3553