Healthcare Provider Details

I. General information

NPI: 1356435176
Provider Name (Legal Business Name): PRIMARY CARE OF THE TREASURE COAST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 36TH ST
VERO BEACH FL
32960-6574
US

IV. Provider business mailing address

1265 36TH ST
VERO BEACH FL
32960-6574
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-6340
  • Fax: 772-567-6788
Mailing address:
  • Phone: 772-567-6340
  • Fax: 772-567-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK M LUTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 772-567-6340