Healthcare Provider Details

I. General information

NPI: 1104311315
Provider Name (Legal Business Name): SANTOS PRIMARY CARE MEDICAL CLINICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17820 SE 109TH AVE STE 108
SUMMERFIELD FL
34491-8968
US

IV. Provider business mailing address

17820 SE 109TH AVE STE 108
SUMMERFIELD FL
34491-8968
US

V. Phone/Fax

Practice location:
  • Phone: 352-448-6469
  • Fax: 352-504-0901
Mailing address:
  • Phone: 352-448-6469
  • Fax: 352-504-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ADAMASTOR SANTOS
Title or Position: PROVIDER
Credential: PA
Phone: 352-448-6469