Provider Demographics
NPI:1982654299
Name:ADVENT FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:ADVENT FAMILY PRACTICE, INC
Other - Org Name:ADVENT FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:KANKAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-792-7484
Mailing Address - Street 1:1447 MEDICAL PARK BLVD.
Mailing Address - Street 2:405
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3164
Mailing Address - Country:US
Mailing Address - Phone:561-792-7484
Mailing Address - Fax:561-792-7454
Practice Address - Street 1:1447 MEDICAL PARK BLVD
Practice Address - Street 2:405
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3164
Practice Address - Country:US
Practice Address - Phone:561-792-7484
Practice Address - Fax:561-792-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBK6520806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260022600Medicaid
FL49526ZMedicare ID - Type Unspecified
FL260022600Medicaid