Provider Demographics
NPI:1063570364
Name:FLORIDA MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:FLORIDA MEDICAL CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELATORRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-780-8440
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:38101 MARKET SQ
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-7505
Practice Address - Country:US
Practice Address - Phone:813-782-5587
Practice Address - Fax:813-355-5049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA MEDICAL CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2350332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621212300Medicaid
FL1176890003Medicare NSC