Basic Information
Provider Information | |||||||||
NPI: | 1770144065 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | QUICK CARE MED, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2066 | ||||||||
Address2: |   | ||||||||
City: | LECANTO | ||||||||
State: | FL | ||||||||
PostalCode: | 344602066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525630931 | ||||||||
FaxNumber: | 3525630935 | ||||||||
Practice Location | |||||||||
Address1: | 3415 E SILVER SPRINGS BLVD | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344706405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526297336 | ||||||||
FaxNumber: | 3526907633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2019 | ||||||||
LastUpdateDate: | 06/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | JEANETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3526348736 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | QUICK CARE MED LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 003672416 | 05 | FL |   | MEDICAID |