Provider Demographics
NPI:1730637877
Name:THE CLINIC ST PETE
Entity Type:Organization
Organization Name:THE CLINIC ST PETE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:845-608-3312
Mailing Address - Street 1:11 PLAZA REAL S APT 1003
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-4899
Mailing Address - Country:US
Mailing Address - Phone:845-608-3312
Mailing Address - Fax:
Practice Address - Street 1:4100 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6304
Practice Address - Country:US
Practice Address - Phone:845-608-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty