Healthcare Provider Details

I. General information

NPI: 1073099461
Provider Name (Legal Business Name): CITRUS MULTI CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 SE 7TH AVE STE 1
CRYSTAL RIVER FL
34429-4848
US

IV. Provider business mailing address

255 SE 7TH AVE STE 3
CRYSTAL RIVER FL
34429-4848
US

V. Phone/Fax

Practice location:
  • Phone: 352-794-6385
  • Fax:
Mailing address:
  • Phone: 352-302-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDIE UNDERWOOD
Title or Position: OWNER
Credential:
Phone: 352-302-2223