Provider Demographics
NPI:1225131477
Name:ARDENT FAMILY CARE PA
Entity Type:Organization
Organization Name:ARDENT FAMILY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:ASCENSIO
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-439-9777
Mailing Address - Street 1:84 PINNACLES DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-2324
Mailing Address - Country:US
Mailing Address - Phone:386-439-9777
Mailing Address - Fax:386-206-0015
Practice Address - Street 1:84 PINNACLES DR STE 200
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2324
Practice Address - Country:US
Practice Address - Phone:386-439-9777
Practice Address - Fax:386-206-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD049208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253950100Medicaid
FL21763Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER