Provider Demographics
NPI:1578937140
Name:FLORIDA MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:FLORIDA MEDICAL CLINIC LLC
Other - Org Name:FLORIDA MEDICAL CLINIC EYE CENTER TPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELATORRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-780-8774
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:13602 N 46TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4931
Practice Address - Country:US
Practice Address - Phone:813-972-4444
Practice Address - Fax:813-979-1600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA MEDICAL CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5641332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1176890010Medicare NSC