Provider Demographics
NPI:1962464248
Name:FAMILY HEALTH CENTER OF COLUMBIA COUNTY, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER OF COLUMBIA COUNTY, INC.
Other - Org Name:SELECTED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-758-5552
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-0249
Mailing Address - Country:US
Mailing Address - Phone:386-758-5552
Mailing Address - Fax:386-752-9143
Practice Address - Street 1:173 NW ALBRITTON LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-0249
Practice Address - Country:US
Practice Address - Phone:386-758-5552
Practice Address - Fax:386-752-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92183207Q00000X
FL5080000065261Q00000X
FLPA0003548363A00000X
FLPA9101298363A00000X
FL1181972363L00000X
FLARNP2908802363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023552300Medicaid
FL292277100Medicaid
FLME92183OtherSTATE LICENSE
FL033364600Medicaid
FLPA9101298OtherFLORIDA LICENSE
FL5080000065OtherORIGINAL LICENSE
FLPA0003548OtherFLORIDA LICENSE
FL1181972OtherFLORIDA LICENSE
FL273713200Medicaid
FL290374100Medicaid
FL1181972OtherFLORIDA LICENSE
FL292277100Medicaid
FL033364600Medicaid