Healthcare Provider Details

I. General information

NPI: 1497421267
Provider Name (Legal Business Name): WILLISTON PEDIATRICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 08/20/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N MAIN ST
WILLISTON FL
32696-2136
US

IV. Provider business mailing address

223 N MAIN ST
WILLISTON FL
32696-2136
US

V. Phone/Fax

Practice location:
  • Phone: 352-529-0477
  • Fax: 352-529-0406
Mailing address:
  • Phone: 352-529-0477
  • Fax: 352-529-0406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES LEE QUINLAN
Title or Position: PRESIDENT
Credential: APRN
Phone: 352-529-0477