Provider Demographics
NPI:1275601023
Name:DESTIN PRIMARY CARE LLC
Entity Type:Organization
Organization Name:DESTIN PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCIDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-837-5562
Mailing Address - Street 1:996 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2824
Mailing Address - Country:US
Mailing Address - Phone:850-837-5562
Mailing Address - Fax:850-837-6085
Practice Address - Street 1:996 AIRPORT RD
Practice Address - Street 2:SUITE E 103
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2824
Practice Address - Country:US
Practice Address - Phone:850-837-5562
Practice Address - Fax:850-837-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty