Provider Demographics
NPI:1952423113
Name:PRIMA VISTA WALK-IN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:PRIMA VISTA WALK-IN MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-878-7311
Mailing Address - Street 1:784 E PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2271
Mailing Address - Country:US
Mailing Address - Phone:772-878-7311
Mailing Address - Fax:772-878-7321
Practice Address - Street 1:784 E PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2271
Practice Address - Country:US
Practice Address - Phone:772-878-7311
Practice Address - Fax:772-878-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL72956OtherGRP # FACILITY
FL79256Medicare PIN
FL72956Medicare PIN
FL72956OtherGRP # FACILITY
FLP00146779Medicare PIN