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General NPI Number Information
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NPI Number | 1851575377
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Entity Type | Organization
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Legal Business Name | FAMILY HEALTH CENTER AT PORT ST JOHN LLC
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Dates
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Enumeration Date | 12/19/2007
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Last Update Date | 12/03/2013
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Provider Practice Location Address
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Address Line | 3740 CURTIS BLVD SUITE 108
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City | COCOA
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State | FL
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Zip | 32927-3962
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Country | US
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Telephone | 321-633-5500
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Fax | 321-633-5566
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Provider Business Mailing Address
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Address Line | 3740 CURTIS BLVD SUITE 108
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City | COCOA
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State | FL
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Zip | 32927-3962
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Country | US
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Telephone | 321-633-5500
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Fax | 321-633-5566
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. JANIS G BLACK
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Credential | D.O.
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Telephone | 321-633-5500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS9694
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License Number State | FL
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