=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043613466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2014
-----------------------------------------------------
Last Update Date | 09/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 W OAK ST
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34741-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-287-6866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 W OAK ST
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34741-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-287-6866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | CARLOS ORTIZ DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-287-6866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------