MEDICARE: PINE CASTLE URGENT CARE CENTER PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1982880613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE CASTLE URGENT CARE CENTER PLLC

Provider Business Mailing Address
First Line	:	5636 HANSEL AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-4216
Country	:	US
Telephone Number	:	407-850-0056
Fax Number	:

Provider Business Practice Location Address
First Line	:	5636 HANSEL AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-4216
Country	:	US
Telephone Number	:	407-850-0056
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	NINO DIIULLO
Credential	:	M.D.
Telephone Number	:	614-880-5340

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	06/13/2008

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