=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386364032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACHSIDE PRIMARY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2022
-----------------------------------------------------
Last Update Date | 12/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1825 3RD ST N STE B
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-595-5826
-----------------------------------------------------
Fax | 904-595-5827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1825 3RD ST N STE B
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DEBORAH GHANDOUR
-----------------------------------------------------
Credential | PA-C, DHSC
-----------------------------------------------------
Telephone | 904-595-5826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------