=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295920676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUICMED WALK IN CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2007
-----------------------------------------------------
Last Update Date | 12/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11223 N WILLIAMS ST
-----------------------------------------------------
City | DUNNELLON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34432-8350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-522-1101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11223 N WILLIAMS ST
-----------------------------------------------------
City | DUNNELLON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34432-8350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-522-1101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | DR. JOHN T CHACKO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 352-522-1101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME74735
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME74735
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ME74735
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------