Healthcare Provider Details

I. General information

NPI: 1336654763
Provider Name (Legal Business Name): PHYSICIANS GROUP OF THE TREASURE COAST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 SE INDIAN ST
STUART FL
34997-5765
US

IV. Provider business mailing address

1131 SE INDIAN ST
STUART FL
34997-5765
US

V. Phone/Fax

Practice location:
  • Phone: 772-617-0124
  • Fax: 772-223-5110
Mailing address:
  • Phone: 772-617-0124
  • Fax: 772-223-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA TUCKER
Title or Position: OWNER
Credential:
Phone: 772-219-1355