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General NPI Number Information
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NPI Number | 1811463961
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Entity Type | Organization
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Legal Business Name | ISLAND DIRECT PRIMARY CARE LLC
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Dates
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Enumeration Date | 10/16/2018
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Last Update Date | 03/27/2022
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Provider Practice Location Address
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Address Line | 390 N COURTENAY PKWY
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-3456
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Country | US
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Telephone | 321-506-2540
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Fax |
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Provider Business Mailing Address
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Address Line | 210 HICKORY AVE
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4368
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Country | US
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Telephone | 321-506-2540
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN WESLEY ROTHWELL III
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Credential | DNP
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Telephone | 321-506-2540
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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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