Healthcare Provider Details

I. General information

NPI: 1235533829
Provider Name (Legal Business Name): HEEKIN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2014
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 RIVERSIDE AVE STE 100
JACKSONVILLE FL
32204-4148
US

IV. Provider business mailing address

1045 RIVERSIDE AVE STE 100
JACKSONVILLE FL
32204-4148
US

V. Phone/Fax

Practice location:
  • Phone: 904-328-5979
  • Fax: 904-619-9925
Mailing address:
  • Phone: 904-328-5979
  • Fax: 904-619-9925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberME49020
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: FADY EL BAHRI
Title or Position: OWNER
Credential: MD
Phone: 904-328-5979