Provider Demographics
NPI:1467684878
Name:PHYSIOCARE MEDICAL & WELLNESS CENTER
Entity Type:Organization
Organization Name:PHYSIOCARE MEDICAL & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:407-240-8884
Mailing Address - Street 1:8204 CRYSTAL CLEAR LN
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-7758
Mailing Address - Country:US
Mailing Address - Phone:407-240-8884
Mailing Address - Fax:407-240-8388
Practice Address - Street 1:8204 CRYSTAL CLEAR LN
Practice Address - Street 2:SUITE 1500
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7758
Practice Address - Country:US
Practice Address - Phone:407-240-8884
Practice Address - Fax:407-240-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5023302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization