=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194060202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEANSIDE URGENT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2012
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11786 SE FEDERAL HWY SUITE B
-----------------------------------------------------
City | HOBE SOUND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33455-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-546-4215
-----------------------------------------------------
Fax | 772-546-8741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11786 SE FEDERAL HWY SUITE B
-----------------------------------------------------
City | HOBE SOUND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33455-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-546-4215
-----------------------------------------------------
Fax | 772-546-8741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THERESA GOEBEL
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 772-546-4215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | OS8519
-----------------------------------------------------
License Number State | ZZ
-----------------------------------------------------