Healthcare Provider Details

I. General information

NPI: 1255362034
Provider Name (Legal Business Name): MILL CREEK FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W TOWN PL SUITE 105
ST AUGUSTINE FL
32092-3648
US

IV. Provider business mailing address

475 W TOWN PL SUITE 105
ST AUGUSTINE FL
32092-3648
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-1441
  • Fax: 904-940-1490
Mailing address:
  • Phone: 904-940-1441
  • Fax: 904-940-1490

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: DR. TRACI L BRAGG
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 904-940-1441