Healthcare Provider Details

I. General information

NPI: 1962060939
Provider Name (Legal Business Name): QUICK CARE MED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 W NOBLE AVE
WILLISTON FL
32696
US

IV. Provider business mailing address

PO BOX 2066
LECANTO FL
34460-2066
US

V. Phone/Fax

Practice location:
  • Phone: 352-528-9355
  • Fax: 352-528-7427
Mailing address:
  • Phone: 352-563-0931
  • Fax: 352-563-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JEANETTE SMITH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 352-634-8736