Provider Demographics
NPI:1497806715
Name:REGAL FAMILY CARE, INC.
Entity Type:Organization
Organization Name:REGAL FAMILY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-243-0206
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34755-2379
Mailing Address - Country:US
Mailing Address - Phone:352-243-0206
Mailing Address - Fax:352-243-1822
Practice Address - Street 1:1120 CITRUS TOWER BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1909
Practice Address - Country:US
Practice Address - Phone:352-243-0206
Practice Address - Fax:352-243-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09918OtherBCBS OF FLORIDA
K8295Medicare ID - Type Unspecified
FLF75285Medicare UPIN