=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467924019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUESTCARE TELEHEALTH FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2018
-----------------------------------------------------
Last Update Date | 12/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 SE TIFFANY AVE
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13737 NOEL RD #1600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75240-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-838-2371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | KATHLEEN KONDAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------