Provider Demographics
NPI:1811598105
Name:FOUNDATIONS MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:FOUNDATIONS MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-269-9000
Mailing Address - Street 1:4467 COMMONS DR W STE F-G
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8454
Mailing Address - Country:US
Mailing Address - Phone:850-269-9000
Mailing Address - Fax:850-269-9002
Practice Address - Street 1:4467 COMMONS DR W STE F-G
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8454
Practice Address - Country:US
Practice Address - Phone:850-269-9000
Practice Address - Fax:850-269-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty