Healthcare Provider Details

I. General information

NPI: 1558128819
Provider Name (Legal Business Name): PEDIM OUTREACH AND SPECIALTY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 W FLARE LN
LECANTO FL
34461
US

IV. Provider business mailing address

PO BOX 2066
LECANTO FL
34460-2066
US

V. Phone/Fax

Practice location:
  • Phone: 352-527-6888
  • Fax:
Mailing address:
  • Phone: 352-634-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DACELIN ST MARTIN
Title or Position: OWNER
Credential: MD
Phone: 352-527-6888