=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760152508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST CHOICE URGENT CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2021
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 W MAIN ST
-----------------------------------------------------
City | LAKE BUTLER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32054-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-962-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 817 NW 56TH TER STE A
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32605-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-336-0964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL CONSULTANT
-----------------------------------------------------
Name | JOHN DISTEFANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-317-3214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------