Provider Demographics
NPI:1720359045
Name:FAMILY CARE CENTER OF BROOKSVILLE, PA
Entity Type:Organization
Organization Name:FAMILY CARE CENTER OF BROOKSVILLE, PA
Other - Org Name:FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:352-596-4482
Mailing Address - Street 1:14540 CORTEZ BLVD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6056
Mailing Address - Country:US
Mailing Address - Phone:352-596-4482
Mailing Address - Fax:352-596-2241
Practice Address - Street 1:14540 CORTEZ BLVD
Practice Address - Street 2:SUITE 118
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6056
Practice Address - Country:US
Practice Address - Phone:352-596-4482
Practice Address - Fax:352-596-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007621261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care