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General NPI Number Information
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NPI Number | 1760802458
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Entity Type | Organization
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Legal Business Name | THE GOOD SAMARITAN FREE CLINIC, INC
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Dates
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Enumeration Date | 04/21/2014
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Last Update Date | 04/21/2014
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Provider Practice Location Address
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Address Line | 2601 VIRGINIA AVE
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City | FORT PIERCE
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State | FL
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Zip | 34981-5539
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Country | US
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Telephone | 772-924-1137
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3035
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City | FORT PIERCE
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State | FL
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Zip | 34948-3035
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Country | US
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Telephone | 772-924-1137
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE ASSISTANT
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Name | EVA BRYANT
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Credential | R.N.
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Telephone | 772-879-9383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | RN9338409
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License Number State | FL
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