Provider Demographics
NPI:1811463961
Name:ISLAND DIRECT PRIMARY CARE LLC
Entity type:Organization
Organization Name:ISLAND DIRECT PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:ROTHWELL
Authorized Official - Suffix:III
Authorized Official - Credentials:DNP
Authorized Official - Phone:321-506-2540
Mailing Address - Street 1:210 HICKORY AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4368
Mailing Address - Country:US
Mailing Address - Phone:321-506-2540
Mailing Address - Fax:
Practice Address - Street 1:390 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3456
Practice Address - Country:US
Practice Address - Phone:321-506-2540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1679943740Medicaid