Provider Demographics
NPI:1912177577
Name:FAMILY MEDICAL CARE OF PALM COAST LLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF PALM COAST LLC
Other - Org Name:VICENCIO ANTONIO III
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:SISON
Authorized Official - Last Name:VICENCIO
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:386-586-3466
Mailing Address - Street 1:PO BOX 354339
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-4339
Mailing Address - Country:US
Mailing Address - Phone:386-586-3466
Mailing Address - Fax:386-586-3467
Practice Address - Street 1:21 HOSPITAL DR
Practice Address - Street 2:SUITE 230
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2452
Practice Address - Country:US
Practice Address - Phone:386-586-3466
Practice Address - Fax:386-586-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ695Medicare PIN