Basic Information
| Provider Information | |||||||||
| NPI: | 1336813567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TREASURE COAST COMMUNITY HEALTH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 INDIAN RIVER BLVD STE B210 | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329607113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578224 | ||||||||
| FaxNumber: | 7722133157 | ||||||||
| Practice Location | |||||||||
| Address1: | 12196 COUNTY ROAD 512 | ||||||||
| Address2: | |||||||||
| City: | FELLSMERE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329485463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578224 | ||||||||
| FaxNumber: | 7722133157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | SOULE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7722578224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TREASURE COAST COMMUNITY HEALTH INC | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 680005003 | 05 | FL | MEDICAID |