=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649861790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 360 MEDICAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2021
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14107 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-549-9962
-----------------------------------------------------
Fax | 352-549-9963
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14107 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-549-9962
-----------------------------------------------------
Fax | 352-549-9963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | GATUAM THAKKAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-549-9962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------