Provider Demographics
NPI:1578919080
Name:OUTPATIENT CLINIC AT PENNEY RETIREMENT COMMUNITY, INC.
Entity Type:Organization
Organization Name:OUTPATIENT CLINIC AT PENNEY RETIREMENT COMMUNITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-531-7022
Mailing Address - Street 1:2 NORTH PAVILION PLACE
Mailing Address - Street 2:
Mailing Address - City:PENNEY FARMS
Mailing Address - State:FL
Mailing Address - Zip Code:32079
Mailing Address - Country:US
Mailing Address - Phone:904-531-7022
Mailing Address - Fax:
Practice Address - Street 1:2 NORTH PAVILION PLACE
Practice Address - Street 2:
Practice Address - City:PENNEY FARMS
Practice Address - State:FL
Practice Address - Zip Code:32079
Practice Address - Country:US
Practice Address - Phone:904-531-7022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNEY RETIREMENT COMMUNITY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty