Provider Demographics
NPI:1609297928
Name:YOUR FAMILY WALK-IN CLINIC
Entity Type:Organization
Organization Name:YOUR FAMILY WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, ARNP
Authorized Official - Phone:727-580-9131
Mailing Address - Street 1:17929 HUNTING BOW CIR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5378
Mailing Address - Country:US
Mailing Address - Phone:727-580-9131
Mailing Address - Fax:
Practice Address - Street 1:17318 BRIDLEPATH CT
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8400
Practice Address - Country:US
Practice Address - Phone:727-580-9131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-05
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2776972261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1154368883OtherMEDICARE PTAN
FL302641800Medicaid