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General NPI Number Information
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NPI Number | 1194101618
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Entity Type | Organization
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Legal Business Name | PRUDENTIAL URGENT CARE & DIAGNOSTIC, INC.
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Dates
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Enumeration Date | 08/06/2015
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Last Update Date | 02/27/2017
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Provider Practice Location Address
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Address Line | 4101 NW 3RD CT SUITE 3
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City | PLANTATION
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State | FL
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Zip | 33317-2857
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Country | US
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Telephone | 954-530-9280
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Fax | 954-533-1024
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Provider Business Mailing Address
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Address Line | 4101 NW 3RD CT SUITE 3
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City | PLANTATION
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State | FL
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Zip | 33317-2857
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Country | US
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Telephone | 954-530-9280
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Fax | 954-533-1024
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Authorized Official
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Title or Position | MANAGER
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Name | OLLIE ROYSTER
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Credential |
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Telephone | 954-530-9280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | OS1505
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME79405
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | OS1505
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License Number State | FL
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