# SPACE COAST FAMILY PRACTICE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811099054
- **Authorized official:** DR. THOMAS CHARLES BETKA MD (PRESIDENT)
- **Authorized official phone:** (920) 544-5868

## Contact information

- **Practice address:** 3067 WINDLAND DR, GREEN BAY, WI 54311-7574
- **Practice address phone:** (920) 544-5868
- **Mailing address:** 3067 WINDLAND DR, GREEN BAY, WI 54311-7574
- **Mailing address phone:** (920) 544-5868

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | ME88311 | FL | Yes |

## Other

- **Enumeration date:** 09/01/2006
- **Last updated:** 08/22/2020