Provider Demographics
NPI:1518130509
Name:FIRST FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:FIRST FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOUISVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-294-6132
Mailing Address - Street 1:320 1ST ST S STE 200
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3501
Mailing Address - Country:US
Mailing Address - Phone:863-294-6132
Mailing Address - Fax:863-293-8450
Practice Address - Street 1:320 1ST ST S
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3501
Practice Address - Country:US
Practice Address - Phone:863-294-6132
Practice Address - Fax:863-293-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01112353OtherAMERIGROUP