=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356679989
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY CARE PRACTITIONERS OF SOUTH FLORIDA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 NE 2ND AVE
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-894-0522
-----------------------------------------------------
Fax | 954-964-1244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4110
-----------------------------------------------------
City | HALLANDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33008-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-894-0522
-----------------------------------------------------
Fax | 954-455-4435
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | IVORY J CHRISTEN
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 954-894-0522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ARNP1714142
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | OS0001922
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | OS0007497
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ME0049240
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------