Provider Demographics
NPI:1659473833
Name:FAMILY CARE ON EUSTIS SQUARE PA
Entity type:Organization
Organization Name:FAMILY CARE ON EUSTIS SQUARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:352-357-4629
Mailing Address - Street 1:1 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2947
Mailing Address - Country:US
Mailing Address - Phone:352-357-4629
Mailing Address - Fax:352-357-9367
Practice Address - Street 1:1 W PARK AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2947
Practice Address - Country:US
Practice Address - Phone:352-357-4629
Practice Address - Fax:352-357-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2446363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0951OtherMEDICARE GROUP PTAN
FL259149900Medicaid