Provider Demographics
NPI:1053861054
Name:PRIMARY CARE OF PORT ORANGE
Entity Type:Organization
Organization Name:PRIMARY CARE OF PORT ORANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-761-4670
Mailing Address - Street 1:4770 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4544
Mailing Address - Country:US
Mailing Address - Phone:386-761-4670
Mailing Address - Fax:
Practice Address - Street 1:4770 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4544
Practice Address - Country:US
Practice Address - Phone:386-761-4670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9308547302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization