1518268283 NPI number — WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC

Table of content: (NPI 1518268283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518268283 NPI number — WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518268283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3105 INNOVATION DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34769-6501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-498-0539
Provider Business Mailing Address Fax Number:
877-203-2038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 INNOVATION DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34769-6501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-498-0539
Provider Business Practice Location Address Fax Number:
877-203-2038
Provider Enumeration Date:
11/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
NICANOR
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
267-475-8447

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  105419 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: MD037726L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0368398000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 550663UKE . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60018874 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 001759700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5114306 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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