MEDICARE: PRIMARY CARE MEDICAL CTR. 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	207Q00000X	Family Medicine Physician	OS-000748	FL

General Provider Information

NPI Number	:	1780975300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE MEDICAL CTR. LLC

Provider Business Mailing Address
First Line	:	5460 N STATE ROAD 7
Second Line	:	SUITE 110
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33319-2952
Country	:	US
Telephone Number	:	954-533-2471
Fax Number	:

Provider Business Practice Location Address
First Line	:	5460 N STATE ROAD 7
Second Line	:	SUITE 110
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33319-2952
Country	:	US
Telephone Number	:	954-533-2471
Fax Number	:

Authorized Official
Title or Position	:	CEO-MANAGER
Name	:	YVES MICHAEL LAVENTURE
Credential	:	D.O.
Telephone Number	:	954-533-2471

Provider Enumeration Date	:	04/30/2011
Last Update Date	:	04/30/2011

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