Provider Demographics
NPI:1063798478
Name:PHOENIX FAMILY HEALTH CARE CENTER
Entity type:Organization
Organization Name:PHOENIX FAMILY HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MENDEZ CATLIN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:850-697-3420
Mailing Address - Street 1:1581 HIGHWAY 98 W
Mailing Address - Street 2:
Mailing Address - City:CARRABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:32322-5009
Mailing Address - Country:US
Mailing Address - Phone:850-697-3420
Mailing Address - Fax:850-697-3423
Practice Address - Street 1:1581 HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:CARRABELLE
Practice Address - State:FL
Practice Address - Zip Code:32322-5009
Practice Address - Country:US
Practice Address - Phone:850-697-3420
Practice Address - Fax:850-697-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-30
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275192500Medicaid
FL163492Medicare UPIN
FLU8416WMedicare PIN
FL275192500Medicaid