Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 113 E Main St, Mayo, Florida |
Authorized Official Name and Position | Karen Tidwell (CLINIC MANAGER) |
Authorized Official Contact | 8502235409 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
117 Sw Virginia Cir Mayo FL 32066-4065 Ph: (386) 294-2475 | 113 E Main St Mayo FL 32066-4808 Ph: (386) 294-2475 |
NPI Number | 1487613121 |
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Provider Enumeration Date | 03/21/2006 |
Last Update Date | 11/27/2012 |
Medicare PECOS PAC ID | 5092614503 |
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Medicare Enrollment ID | O20060210000200 |
Identifier | Type | State | Issuer |
---|---|---|---|
1487613121 | NPI | - | NPPES |
24274C | Other | BCBS | |
660123500 | Medicaid | FL | |
10D0961929 | Other | CLIA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QR1300X | Clinic/center - Rural Health | 660123500 (Florida) | Primary |