Provider Demographics
NPI:1518355403
Name:FLORIDA COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:FLORIDA COMMUNITY HEALTH CENTER
Other - Org Name:FL COMM HEALTH CENTER-FORT PIERCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GERVASI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-844-9443
Mailing Address - Street 1:1505 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-3975
Mailing Address - Country:US
Mailing Address - Phone:772-462-6520
Mailing Address - Fax:561-472-0391
Practice Address - Street 1:1505 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-3975
Practice Address - Country:US
Practice Address - Phone:772-462-6520
Practice Address - Fax:561-472-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-31
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH29268OtherSTATE LICENSE