Healthcare Provider Details

I. General information

NPI: 1912251562
Provider Name (Legal Business Name): HISCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4577 COLLINS RD
MARIANNA FL
32448-5030
US

IV. Provider business mailing address

4577 COLLINS RD
MARIANNA FL
32448-5030
US

V. Phone/Fax

Practice location:
  • Phone: 850-693-3055
  • Fax: 850-482-5208
Mailing address:
  • Phone: 850-693-3055
  • Fax: 850-482-5208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. ANGELA MCFARLAND
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 850-693-3055