Provider Demographics
NPI:1992179527
Name:TREASURE COAST PRIMARY CARE
Entity Type:Organization
Organization Name:TREASURE COAST PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GLUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:772-800-7340
Mailing Address - Street 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:BUILDING A SUITE 108
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7553
Mailing Address - Country:US
Mailing Address - Phone:772-800-7340
Mailing Address - Fax:772-403-2379
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:BUILDING A SUITE 108
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-800-7340
Practice Address - Fax:772-403-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care