Healthcare Provider Details

I. General information

NPI: 1104247865
Provider Name (Legal Business Name): EXPRESS CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2013
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 W STATE ROAD 434
LONGWOOD FL
32779-4815
US

IV. Provider business mailing address

2650 STATE ROAD 434
LONGWOOD FL
32779
US

V. Phone/Fax

Practice location:
  • Phone: 407-475-3366
  • Fax: 407-475-3367
Mailing address:
  • Phone: 407-475-3366
  • Fax: 407-475-3367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. OLEKSANDR V ONUSHKO
Title or Position: PRESIDENT
Credential: PHD
Phone: 407-475-3367