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9555 E Fowler Ave Thonotosassa FL 33592-2139 | |
(813) 653-6100 | |
Not Available |
Full Name | |
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Speciality | Clinic/Center |
Location | 9555 E Fowler Ave, Thonotosassa, Florida |
Authorized Official Name and Position | Robert R Rodriguez (CFO) |
Authorized Official Contact | 8133497563 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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13110 Elk Mountain Dr Riverview FL 33579-7182 Ph: (813) 349-7588 | 9555 E Fowler Ave Thonotosassa FL 33592-2139 Ph: (813) 653-6100 |
NPI Number | 1609303734 |
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Provider Enumeration Date | 05/19/2017 |
Last Update Date | 06/11/2019 |
Medicare PECOS PAC ID | 3870402548 |
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Medicare Enrollment ID | O20170705001690 |
Identifier | Type | State | Issuer |
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1609303734 | NPI | - | NPPES |
9999 | Other | NA |
Taxonomy | Type | License (State) | Status |
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261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |