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General NPI Number Information
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NPI Number | 1033193743
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Entity Type | Organization
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Legal Business Name | MEMORIAL URGENT CARE MANDARIN LLC
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Dates
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Enumeration Date | 12/06/2005
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Last Update Date | 12/10/2007
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Provider Practice Location Address
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Address Line | 11701 SAN JOSE BLVD SUITE 110
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City | JACKSONVILLE
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State | FL
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Zip | 32223-0756
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Country | US
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Telephone | 904-306-8060
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Fax | 904-306-8065
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Provider Business Mailing Address
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Address Line | 11701-32 SAN JOSE BLVD SUITE 110
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City | JACKSONVILLE
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State | FL
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Zip | 32223-1884
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Country | US
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Telephone | 904-996-7600
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Fax | 904-306-8065
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Authorized Official
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Title or Position | VP
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Name | MR. MICKEY PICKLER
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Credential |
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Telephone | 850-523-2117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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