Provider Demographics
NPI:1366835795
Name:MELBOURNE MEDICAL LLC
Entity type:Organization
Organization Name:MELBOURNE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-751-3862
Mailing Address - Street 1:1600 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4149
Mailing Address - Country:US
Mailing Address - Phone:321-751-3862
Mailing Address - Fax:321-751-3865
Practice Address - Street 1:1600 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4149
Practice Address - Country:US
Practice Address - Phone:321-751-3862
Practice Address - Fax:321-751-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care