Provider Demographics
NPI:1629485271
Name:MEDICAL HOME PL
Entity Type:Organization
Organization Name:MEDICAL HOME PL
Other - Org Name:ALLCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:ELTON
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:727-525-4401
Mailing Address - Street 1:PO BOX 7651
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33734-7651
Mailing Address - Country:US
Mailing Address - Phone:727-922-0009
Mailing Address - Fax:727-525-7788
Practice Address - Street 1:4401 4TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-4728
Practice Address - Country:US
Practice Address - Phone:727-525-4401
Practice Address - Fax:727-525-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102187261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care