Provider Demographics
NPI:1225082332
Name:THREE RIVERS MEDICAL
Entity Type:Organization
Organization Name:THREE RIVERS MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:386-935-1607
Mailing Address - Street 1:208 SUWANNEE AVE NW
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32008-3265
Mailing Address - Country:US
Mailing Address - Phone:386-935-1607
Mailing Address - Fax:386-935-1667
Practice Address - Street 1:208 SUWANNEE AVE NW
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:FL
Practice Address - Zip Code:32008-3265
Practice Address - Country:US
Practice Address - Phone:386-935-1607
Practice Address - Fax:386-935-1667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660195200Medicaid
FL660195200Medicaid