Provider Demographics
NPI: | 1265844757 |
---|---|
Name: | FAMILY MEDICAL CARE OF MOUNT DORA INC |
Entity Type: | Organization |
Organization Name: | FAMILY MEDICAL CARE OF MOUNT DORA INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | N |
Authorized Official - Last Name: | BOUCHER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 407-834-7800 |
Mailing Address - Street 1: | PO BOX 1844 |
Mailing Address - Street 2: | |
Mailing Address - City: | MOUNT DORA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32756-1844 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 352-383-8200 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 17580 US HIGHWAY 441 |
Practice Address - Street 2: | |
Practice Address - City: | MOUNT DORA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32757-6711 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-383-8200 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-06-02 |
Last Update Date: | 2015-01-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | HCC10266 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |