Provider Demographics
NPI:1871991539
Name:FLETA MEDICAL CARE CENTER, LLC
Entity type:Organization
Organization Name:FLETA MEDICAL CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR/ PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LARRAZABAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-334-1295
Mailing Address - Street 1:500 MEMORIAL CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5071
Mailing Address - Country:US
Mailing Address - Phone:386-334-1295
Mailing Address - Fax:
Practice Address - Street 1:2089 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2240
Practice Address - Country:US
Practice Address - Phone:386-767-7533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty