Basic Information
| Provider Information | |||||||||
| NPI: | 1609438019 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUICK CARE MED, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2066 | ||||||||
| Address2: | |||||||||
| City: | LECANTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344602066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525630931 | ||||||||
| FaxNumber: | 3525630935 | ||||||||
| Practice Location | |||||||||
| Address1: | 8119 SW HIGHWAY 200 | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344817733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528549355 | ||||||||
| FaxNumber: | 3528730047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2019 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JEANETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3526348736 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | QUICK CARE MED LLC | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 003672408 | 05 | FL | MEDICAID |