Healthcare Provider Details

I. General information

NPI: 1578919080
Provider Name (Legal Business Name): OUTPATIENT CLINIC AT PENNEY RETIREMENT COMMUNITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 NORTH PAVILION PLACE
PENNEY FARMS FL
32079
US

IV. Provider business mailing address

2 NORTH PAVILION PLACE
PENNEY FARMS FL
32079
US

V. Phone/Fax

Practice location:
  • Phone: 904-531-7022
  • Fax:
Mailing address:
  • Phone: 904-531-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA SCOTT
Title or Position: PRESIDENT
Credential:
Phone: 904-531-7022