=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215262233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTOS DOCTORS INN WALK IN HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2009
-----------------------------------------------------
Last Update Date | 07/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8019 W SAMPLE RD
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-969-9903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8019 W SAMPLE RD
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-969-9903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. CHRISTOPHER JACOB SMITH
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 954-969-9903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | L09000083502
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------