MEDICARE: FLETA MEDICAL CARE CENTER, 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

General Provider Information

NPI Number	:	1871991539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLETA MEDICAL CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	500 MEMORIAL CIR
Second Line	:	SUITE A
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5071
Country	:	US
Telephone Number	:	386-334-1295
Fax Number	:

Provider Business Practice Location Address
First Line	:	2089 S RIDGEWOOD AVE
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-2240
Country	:	US
Telephone Number	:	386-767-7533
Fax Number	:

Authorized Official
Title or Position	:	AR/ PROVIDER
Name	:	MR. PATRICK JOHN LARRAZABAL
Credential	:	MD
Telephone Number	:	386-334-1295

Provider Enumeration Date	:	12/11/2014
Last Update Date	:	12/11/2014

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