Basic Information
Provider Information | |||||||||
NPI: | 1598103004 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DISTRICT CLINIC HOLDINGS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334013429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5616591270 | ||||||||
FaxNumber: | 5618045790 | ||||||||
Practice Location | |||||||||
Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334013429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5616591270 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2013 | ||||||||
LastUpdateDate: | 03/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | DARCY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5618045885 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 008037106 | 05 | FL |   | MEDICAID | 008037124 | 05 | FL |   | MEDICAID | 008037102 | 05 | FL |   | MEDICAID | 008037118 | 05 | FL |   | MEDICAID | 008037100 | 05 | FL |   | MEDICAID | 008037104 | 05 | FL |   | MEDICAID | 008037112 | 05 | FL |   | MEDICAID | 008037123 | 05 | FL |   | MEDICAID |