Provider Demographics
NPI:1891775581
Name:VA PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:VA PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:EILENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:772-595-5150
Mailing Address - Street 1:727 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-9125
Mailing Address - Country:US
Mailing Address - Phone:772-595-5150
Mailing Address - Fax:772-595-6560
Practice Address - Street 1:727 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-9125
Practice Address - Country:US
Practice Address - Phone:772-595-5150
Practice Address - Fax:772-595-6560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW7718261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center