=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629670369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE PARTNERS OF NORTHEAST FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2020
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4565 US HIGHWAY 17 STE 106
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-4822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-4559
-----------------------------------------------------
Fax | 904-269-4597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 W COLONIAL DR STE 303
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-6863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-745-3618
-----------------------------------------------------
Fax | 904-722-4271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DAVID BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 833-702-8383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------