Healthcare Provider Details

I. General information

NPI: 1659612661
Provider Name (Legal Business Name): CRH MQ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2013
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 PINNACLES DR
PALM COAST FL
32164-2322
US

IV. Provider business mailing address

75 14TH ST NE SUITE 2700
ATLANTA GA
30309-3604
US

V. Phone/Fax

Practice location:
  • Phone: 386-597-2829
  • Fax: 386-313-1923
Mailing address:
  • Phone: 404-815-9569
  • Fax: 404-410-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM C MILLER
Title or Position: CEO
Credential:
Phone: 678-592-5847