Healthcare Provider Details

I. General information

NPI: 1508243742
Provider Name (Legal Business Name): PRIMARY CARE SERVICES OF JUPITER MEDICAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 TEQUESTA DR SUITE 12E
TEQUESTA FL
33469-2768
US

IV. Provider business mailing address

5565 CENTERVIEW DR STE 107
RALEIGH NC
27606-3563
US

V. Phone/Fax

Practice location:
  • Phone: 561-263-4477
  • Fax:
Mailing address:
  • Phone:
  • 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: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 877-328-1119