Provider Demographics
NPI:1801054036
Name:DR BEHAL'S FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:DR BEHAL'S FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:D' VAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-232-5062
Mailing Address - Street 1:1138 CARLTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4305
Mailing Address - Country:US
Mailing Address - Phone:863-678-9900
Mailing Address - Fax:863-678-9278
Practice Address - Street 1:1138 CARLTON AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4305
Practice Address - Country:US
Practice Address - Phone:863-678-9900
Practice Address - Fax:863-678-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271785900Medicaid
FL01501OtherBCBS OF FL
FL01501OtherBCBS OF FL
FL01501Medicare PIN