=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982218079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY TOTAL CARE CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2020
-----------------------------------------------------
Last Update Date | 09/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3015 S CONGRESS AVE STE 1
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-308-0818
-----------------------------------------------------
Fax | 561-444-3491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3015 S CONGRESS AVE STE 1
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-308-0818
-----------------------------------------------------
Fax | 561-444-3491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARLENYS PEREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-308-0818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------