Healthcare Provider Details

I. General information

NPI: 1780458554
Provider Name (Legal Business Name): THAIP MEDICAL/COMPLEXITY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 WILSHIRE BLVD STE 238-120
CASSELBERRY FL
32707-5370
US

IV. Provider business mailing address

336 WILSHIRE BLVD STE 238-120
CASSELBERRY FL
32707-5370
US

V. Phone/Fax

Practice location:
  • Phone: 865-213-2834
  • Fax:
Mailing address:
  • Phone: 865-213-2834
  • Fax: 835-213-5169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JACOB READ
Title or Position: PROVIDER
Credential: PMHNP-BC
Phone: 406-860-5138