Provider Demographics
NPI:1851575377
Name:FAMILY HEALTH CENTER AT PORT ST JOHN LLC
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER AT PORT ST JOHN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-633-5500
Mailing Address - Street 1:3740 CURTIS BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-3962
Mailing Address - Country:US
Mailing Address - Phone:321-633-5500
Mailing Address - Fax:321-633-5566
Practice Address - Street 1:3740 CURTIS BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-3962
Practice Address - Country:US
Practice Address - Phone:321-633-5500
Practice Address - Fax:321-633-5566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2753011400Medicaid
FL2753011400Medicaid
FLU8317ZMedicare PIN