Provider Demographics
NPI:1710375456
Name:PRIMARY CARE MEDICAL SERVICES OF POINCIANA INC
Entity Type:Organization
Organization Name:PRIMARY CARE MEDICAL SERVICES OF POINCIANA INC
Other - Org Name:OSCEOLA COMMUNITY HEALTH SERVICES AT POINCIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-CORNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-943-8600
Mailing Address - Street 1:1877 FORTUNE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4428
Mailing Address - Country:US
Mailing Address - Phone:407-943-8600
Mailing Address - Fax:
Practice Address - Street 1:109 N DOVERPLUM AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758
Practice Address - Country:US
Practice Address - Phone:407-943-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000835600Medicaid