Healthcare Provider Details

I. General information

NPI: 1285812362
Provider Name (Legal Business Name): MAITLAND AVENUE URGENT CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 MAITLAND AVE STE 1002
ALTAMONTE SPRINGS FL
32701-5448
US

IV. Provider business mailing address

411 MAITLAND AVE SUITE 1002
ALTAMONTE SPRINGS FL
32701-5448
US

V. Phone/Fax

Practice location:
  • Phone: 321-207-0002
  • Fax: 321-207-2003
Mailing address:
  • Phone: 321-207-0002
  • Fax: 321-207-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberOS5330
License Number StateFL

VIII. Authorized Official

Name: SETH T JOHNSON
Title or Position: PRESIDENT
Credential: D.O.
Phone: 321-207-0002