Basic Information
| Provider Information | |||||||||
| NPI: | 1972809275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDFAST URGENT CARE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160961 | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327160961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217517222 | ||||||||
| FaxNumber: | 3217516655 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 W COCOA BEACH CSWY | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217517222 | ||||||||
| FaxNumber: | 3217516655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2011 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3217997777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDFAST URGENT CARE CENTER, LLC | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
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 |