=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659473833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE ON EUSTIS SQUARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2006
-----------------------------------------------------
Last Update Date | 07/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 W PARK AVE
-----------------------------------------------------
City | EUSTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32726-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-357-4629
-----------------------------------------------------
Fax | 352-357-9367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 W PARK AVE
-----------------------------------------------------
City | EUSTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32726-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-357-4629
-----------------------------------------------------
Fax | 352-357-9367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. KEITH R HESTER
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 352-357-4629
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA2446
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------