Provider Demographics
NPI:1760679088
Name:ABA FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:ABA FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:T
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:386-676-2367
Mailing Address - Street 1:325 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8178
Mailing Address - Country:US
Mailing Address - Phone:386-676-2367
Mailing Address - Fax:386-615-6402
Practice Address - Street 1:325 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8178
Practice Address - Country:US
Practice Address - Phone:386-676-2367
Practice Address - Fax:386-615-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDA2451OtherMEDICARE RAILROAD
FLK4519OtherMEDICARE GROUP NUMBER
FLP00039042OtherMEDICARE RAILROAD INDIVID
FLH11675Medicare UPIN