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General NPI Number Information
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NPI Number | 1346570389
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Entity Type | Organization
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Legal Business Name | MAIN STREET MEDICAL CLINIC
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Dates
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Enumeration Date | 01/13/2010
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Last Update Date | 01/13/2010
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Provider Practice Location Address
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Address Line | 10802 E. MAIN ST STE B
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City | THONOTOSASSA
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State | FL
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Zip | 33592-2840
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Country | US
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Telephone | 813-413-8258
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Fax | 813-413-8310
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Provider Business Mailing Address
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Address Line | 10802 E. MAIN STREET, STE. B
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City | THONOTOSSASSA
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State | FL
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Zip | 33592
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Country | US
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Telephone | 813-413-8258
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Fax | 813-413-8310
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. OMOSALEWA OGUNDIPE
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Credential |
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Telephone | 813-413-8258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME88205
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License Number State | FL
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