Provider Demographics
NPI:1497106504
Name:CENTERCARE FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:CENTERCARE FAMILY PRACTICE, LLC
Other - Org Name:PEDSPLUS PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICKELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURORE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:239-691-5450
Mailing Address - Street 1:1010 W KENSINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8003
Mailing Address - Country:US
Mailing Address - Phone:239-691-5450
Mailing Address - Fax:
Practice Address - Street 1:1300 EMANCIPATION HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4600
Practice Address - Country:US
Practice Address - Phone:540-289-2273
Practice Address - Fax:540-699-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty