Provider Demographics
NPI:1376960351
Name:FLORIDA PRIMARY CARE GROUP. LLC
Entity Type:Organization
Organization Name:FLORIDA PRIMARY CARE GROUP. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-378-5300
Mailing Address - Street 1:3861 AVALON PARK EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4853
Mailing Address - Country:US
Mailing Address - Phone:407-378-5300
Mailing Address - Fax:407-745-5589
Practice Address - Street 1:3861 AVALON PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4853
Practice Address - Country:US
Practice Address - Phone:407-378-5300
Practice Address - Fax:407-745-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care