Full Name | |
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Speciality | Family Medicine |
Location | 3250 Main St, Vernon, Florida |
Authorized Official Name and Position | Steven Lisenby (CHIEF FINANCIAL OFFICER) |
Authorized Official Contact | 8504158107 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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3250 Main St Vernon FL 32462-2223 Ph: (850) 535-2096 | 3250 Main St Vernon FL 32462 Ph: (850) 535-2096 |
NPI Number | 1134422470 |
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Provider Enumeration Date | 12/08/2010 |
Last Update Date | 11/25/2024 |
Medicare PECOS PAC ID | 2668363771 |
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Medicare Enrollment ID | O20110718000120 |
Identifier | Type | State | Issuer |
---|---|---|---|
1134422470 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | 4005 (Florida) | Primary |