Basic Information
| Provider Information | |||||||||
| NPI: | 1285735605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDFAST URGENT CARE CENTERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7925 N WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217517222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7925 N WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218907052 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3217517222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OS6588 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | OS6588 | 01 | FL | MEDICAL LICENSE | OTHER |