Provider Demographics
NPI:1003167073
Name:PRIMARY CARE IN YOUR HOME LLC
Entity Type:Organization
Organization Name:PRIMARY CARE IN YOUR HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROKER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:386-316-5439
Mailing Address - Street 1:341 W MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-2205
Mailing Address - Country:US
Mailing Address - Phone:386-316-5439
Mailing Address - Fax:
Practice Address - Street 1:341 W MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-2205
Practice Address - Country:US
Practice Address - Phone:386-316-5439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-30
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3333802261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305918900Medicaid
FLU1748XMedicare PIN
FLQ01970Medicare UPIN
FL305918900Medicaid
FLG23040Medicare UPIN
FL1518927763Medicare NSC