Healthcare Provider Details

I. General information

NPI: 1295910834
Provider Name (Legal Business Name): PRIMARY CARE CENTER OF PORT ORANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 S RIDGEWOOD AVE SUITE 1
PORT ORANGE FL
32127-4544
US

IV. Provider business mailing address

4770 S RIDGEWOOD AVE SUITE 1
PORT ORANGE FL
32127-4544
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-0050
  • Fax: 386-761-1167
Mailing address:
  • Phone: 386-761-0050
  • Fax: 386-761-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0028054
License Number StateFL

VIII. Authorized Official

Name: MS. MICHELLE L JACKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-761-0050