Provider Demographics
NPI:1972683910
Name:BOCA GRANDE HEALTH CLINIC
Entity type:Organization
Organization Name:BOCA GRANDE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-964-2276
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:BOCA GRANDE
Mailing Address - State:FL
Mailing Address - Zip Code:33921
Mailing Address - Country:US
Mailing Address - Phone:941-964-2276
Mailing Address - Fax:941-964-0158
Practice Address - Street 1:320 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:BOCA GRANDE
Practice Address - State:FL
Practice Address - Zip Code:33921
Practice Address - Country:US
Practice Address - Phone:941-964-2276
Practice Address - Fax:941-964-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL72132Medicare ID - Type Unspecified