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General NPI Number Information
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NPI Number | 1710674205
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Entity Type | Organization
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Legal Business Name | PEDIM OUTREACH AND SPECIALTY CLINIC LLC
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Dates
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Enumeration Date | 04/24/2023
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Last Update Date | 02/13/2025
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Provider Practice Location Address
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Address Line | 3565 E SUZIE LN
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City | INVERNESS
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State | FL
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Zip | 34452-3250
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Country | US
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Telephone | 352-527-6888
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2066
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City | LECANTO
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State | FL
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Zip | 34460-2066
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Country | US
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Telephone | 352-634-8736
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DACELIN ST MARTIN
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Credential | MD
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Telephone | 352-684-8736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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