=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134504855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METCARE OF FLORIDA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2015
-----------------------------------------------------
Last Update Date | 08/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3641 CLYDE MORRIS BLVD SUITE 100
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32129-2357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-500-2114
-----------------------------------------------------
Fax | 305-370-6024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6101 BLUE LAGOON DR STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-500-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE DIRECTOR
-----------------------------------------------------
Name | JESSICA BONETTI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-500-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------