Provider Demographics
NPI:1336654763
Name:PHYSICIANS GROUP OF THE TREASURE COAST LLC
Entity Type:Organization
Organization Name:PHYSICIANS GROUP OF THE TREASURE COAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-219-1355
Mailing Address - Street 1:1131 SE INDIAN ST
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-5765
Mailing Address - Country:US
Mailing Address - Phone:772-617-0124
Mailing Address - Fax:772-223-5110
Practice Address - Street 1:1131 SE INDIAN ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-5765
Practice Address - Country:US
Practice Address - Phone:772-617-0124
Practice Address - Fax:772-223-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty