=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093905986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URGENT CARE CENTER OF LONGWOOD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 W STATE ROAD 434 STE 1010
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-5187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-212-3000
-----------------------------------------------------
Fax | 407-212-3001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 W STATE ROAD 434 STE 1010
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-5187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-212-3000
-----------------------------------------------------
Fax | 407-212-3001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WASIM AHMAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-212-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------