Provider Demographics
NPI:1760802458
Name:THE GOOD SAMARITAN FREE CLINIC, INC
Entity Type:Organization
Organization Name:THE GOOD SAMARITAN FREE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:772-879-9383
Mailing Address - Street 1:PO BOX 3035
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34948-3035
Mailing Address - Country:US
Mailing Address - Phone:772-924-1137
Mailing Address - Fax:
Practice Address - Street 1:2601 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5539
Practice Address - Country:US
Practice Address - Phone:772-924-1137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9338409302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization