Provider Demographics
NPI:1649558701
Name:ANDRELICA INC
Entity Type:Organization
Organization Name:ANDRELICA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ORLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA-SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-237-4719
Mailing Address - Street 1:10616 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6401
Mailing Address - Country:US
Mailing Address - Phone:772-237-4719
Mailing Address - Fax:772-237-4738
Practice Address - Street 1:10616 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6401
Practice Address - Country:US
Practice Address - Phone:772-237-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-23
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000174900Medicaid