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General NPI Number Information
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NPI Number | 1508489790
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Entity Type | Organization
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Legal Business Name | PHOENIX PRIMARY CARE LLC
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Dates
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Enumeration Date | 05/21/2020
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 26B OFFICE PARK DR
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City | PALM COAST
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State | FL
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Zip | 32137-3808
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Country | US
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Telephone | 386-597-2861
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Fax | 844-272-3971
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Provider Business Mailing Address
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Address Line | PO BOX 354925
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City | PALM COAST
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State | FL
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Zip | 32135-4925
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Country | US
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Telephone | 386-597-2861
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Fax | 844-272-3971
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Authorized Official
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Title or Position | CEO
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Name | MS. SANDRA SHANK
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Credential |
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Telephone | 386-597-2861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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