Provider Demographics
NPI:1922370451
Name:NATURE COAST FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:NATURE COAST FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FRANKENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-544-0610
Mailing Address - Street 1:675 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2823
Mailing Address - Country:US
Mailing Address - Phone:352-544-0610
Mailing Address - Fax:352-684-4796
Practice Address - Street 1:675 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2823
Practice Address - Country:US
Practice Address - Phone:352-544-0610
Practice Address - Fax:352-684-4796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57648Medicare PIN