Provider Demographics
NPI:1104106525
Name:PATIENT CONNECT HEALTHCARE CLINIC LLC
Entity type:Organization
Organization Name:PATIENT CONNECT HEALTHCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-490-6326
Mailing Address - Street 1:6350 CENTRAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1430
Mailing Address - Country:US
Mailing Address - Phone:727-490-6326
Mailing Address - Fax:
Practice Address - Street 1:6350 CENTRAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1430
Practice Address - Country:US
Practice Address - Phone:727-490-6326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLC9743261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center