Healthcare Provider Details

I. General information

NPI: 1952900953
Provider Name (Legal Business Name): SALTWATER FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 CLYDE MORRIS BLVD STE 200
ORMOND BEACH FL
32174-8182
US

IV. Provider business mailing address

156 TUSCANY BEND ST
DAYTONA BEACH FL
32117-5545
US

V. Phone/Fax

Practice location:
  • Phone: 386-281-0939
  • Fax:
Mailing address:
  • Phone: 386-281-0939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANDREA LEE MERCADO
Title or Position: APRN
Credential: APRN
Phone: 386-281-0939