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105 Whitehall Dr Suites 109-114 St Augustine FL 32086-5269 | |
| (904) 829-2782 | |
| (904) 829-2494 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 105 Whitehall Dr, St Augustine, Florida |
| Authorized Official Name and Position | Laura M. Spencer (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Contact | 3863280108 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1302 River St Palatka FL 32177-5042 Ph: (386) 328-0108 | 105 Whitehall Dr Suites 109-114 St Augustine FL 32086-5269 Ph: (904) 829-2782 |
| NPI Number | 1629324751 |
|---|---|
| Provider Enumeration Date | 07/26/2012 |
| Last Update Date | 02/12/2020 |
| Medicare PECOS PAC ID | 7214849520 |
|---|---|
| Medicare Enrollment ID | O20121012000484 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629324751 | NPI | - | NPPES |
| 029543414 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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