Healthcare Provider Details

I. General information

NPI: 1083016414
Provider Name (Legal Business Name): EXPRESS CARE CLINIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 11/12/2014
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 W STATE ROAD 434
LONGWOOD FL
32779-4815
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 TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: OLEKSANDR V ONUSHKO
Title or Position: PRESIDENT
Credential:
Phone: 407-475-3366