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General NPI Number Information
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NPI Number | 1710049671
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Entity Type | Organization
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Legal Business Name | THREE RIVERS MEDICAL INC.
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Dates
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Enumeration Date | 12/15/2006
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Last Update Date | 02/04/2010
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Provider Practice Location Address
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Address Line | 208 SUWANNEE AVE NW
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City | BRANFORD
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State | FL
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Zip | 32008-3265
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Country | US
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Telephone | 386-935-1607
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Fax | 386-935-1667
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Provider Business Mailing Address
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Address Line | 208 SUWANNEE AVE NW
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City | BRANFORD
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State | FL
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Zip | 32008-3265
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Country | US
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Telephone | 386-935-1607
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Fax | 386-935-1667
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MS. PEGGY L MALONEY
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Credential |
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Telephone | 386-935-1607
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2934442
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License Number State | FL
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