Provider Demographics
NPI:1275962680
Name:PROFESSIONAL FAMILY PRACTICE
Entity Type:Organization
Organization Name:PROFESSIONAL FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PURNAMA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MADRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-404-7707
Mailing Address - Street 1:2105 HARTWOOD MARSH RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5389
Mailing Address - Country:US
Mailing Address - Phone:352-404-7707
Mailing Address - Fax:888-488-0722
Practice Address - Street 1:725 ALMOND ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3120
Practice Address - Country:US
Practice Address - Phone:352-404-7707
Practice Address - Fax:888-488-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85427261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care