MEDICARE: FIRST COAST DIABETES INSTITUTE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1588903231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST COAST DIABETES INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	1166 AUTUMN POINT CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-9029
Country	:	US
Telephone Number	:	904-703-3041
Fax Number	:

Provider Business Practice Location Address
First Line	:	1126 UNIVERSITY BLVD N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-8850
Country	:	US
Telephone Number	:	904-384-9303
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MARCIO CORREA
Credential	:
Telephone Number	:	904-703-3041

Provider Enumeration Date	:	01/31/2013
Last Update Date	:	01/31/2013

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