Provider Demographics
NPI:1982002945
Name:PRIMARY CARE MEDICAL SERVICES OF POINCIANA INC
Entity Type:Organization
Organization Name:PRIMARY CARE MEDICAL SERVICES OF POINCIANA INC
Other - Org Name:OSCEOLA COMMUNITY HEALTH SERVICES AT STADIUM PLACE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-CORNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-943-8600
Mailing Address - Street 1:1877 FORTUNE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4428
Mailing Address - Country:US
Mailing Address - Phone:407-943-8600
Mailing Address - Fax:407-932-5140
Practice Address - Street 1:1501-1507 BILL BECK BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744
Practice Address - Country:US
Practice Address - Phone:407-943-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000835600Medicaid