Provider Demographics
NPI:1871503797
Name:PELICAN BEACH INC
Entity Type:Organization
Organization Name:PELICAN BEACH INC
Other - Org Name:33RD STREET FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTHCARE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VILMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NCMA
Authorized Official - Phone:407-648-0076
Mailing Address - Street 1:4382 LB MCLEOD RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811
Mailing Address - Country:US
Mailing Address - Phone:407-648-0076
Mailing Address - Fax:407-648-3666
Practice Address - Street 1:4382 LB MCLEOD RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811
Practice Address - Country:US
Practice Address - Phone:407-648-0076
Practice Address - Fax:407-648-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB888AOtherPTAN