Basic Information
| Provider Information | |||||||||
| NPI: | 1124373113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DISTRICT CLINIC HOLDINGS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
| FaxNumber: | 5618339469 | ||||||||
| Practice Location | |||||||||
| Address1: | 39200 HOOKER HWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334305368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616421000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5618045885 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 008037105 | 05 | FL | MEDICAID | 018943201 | 05 | FL | MEDICAID | 008037104 | 05 | FL | MEDICAID |