Provider Demographics
NPI:1700553633
Name:MYRTLE RIDGE PRIMARY CARE, P.A
Entity Type:Organization
Organization Name:MYRTLE RIDGE PRIMARY CARE, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YUDAISY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-909-7102
Mailing Address - Street 1:1539 DALE MABRY HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-3008
Mailing Address - Country:US
Mailing Address - Phone:813-909-7102
Mailing Address - Fax:813-909-0199
Practice Address - Street 1:1539 DALE MABRY HWY STE 102
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3008
Practice Address - Country:US
Practice Address - Phone:813-909-7102
Practice Address - Fax:813-909-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111603900Medicaid