=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598537359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVACARE FLORIDA URGENT CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2023
-----------------------------------------------------
Last Update Date | 10/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15689 SOUTHERN BLVD UNIT 102
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-9229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-798-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6900 TAVISTOCK LAKES BLVD STE 300
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32827-7592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | PENELOPE KOKKINIDES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-270-7825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------