Provider Demographics
NPI:1073611067
Name:MARIANNA FAMILY CARE CENTER LLC
Entity Type:Organization
Organization Name:MARIANNA FAMILY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HORACIO
Authorized Official - Middle Name:JORGE
Authorized Official - Last Name:RODRIGUEZ-JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-526-3555
Mailing Address - Street 1:2928 DANIELS ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2912
Mailing Address - Country:US
Mailing Address - Phone:850-526-3555
Mailing Address - Fax:850-526-3570
Practice Address - Street 1:2928 DANIELS STREET
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-526-3555
Practice Address - Fax:850-526-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45283OtherBCBS
FL255784300Medicaid
FLDC0337OtherRR MEDICARE
FL45283Medicare ID - Type Unspecified