Basic Information
| Provider Information | |||||||||
| NPI: | 1396997532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKEWOOD RANCH URGENT CARE, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRADENTON URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7322 MANATEE AVE W #108 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414475854 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4647 MANATEE AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342093849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417455999 | ||||||||
| FaxNumber: | 9417495915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 09/12/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOLKENS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9414475854 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.