=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154697217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROWARD GENERAL URGENT CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2012
-----------------------------------------------------
Last Update Date | 11/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3267 DAVIE BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-2755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-584-7449
-----------------------------------------------------
Fax | 954-584-7209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 NE 198TH TER
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-3133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-524-7449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREA CARRASCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-797-3187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | HCC9370
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------