MEDICARE: WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	MD037726L	PA
2	261Q00000X	Clinic/Center	105419	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	550663UKE	OTHER	NJ	MEDICARE ID-TYPE UNSPECIFIED

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0368398000	OTHER	NJ	AMERIHEALTH
3	60018874	OTHER	NJ	HORIZON NJ HEALTH
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518268283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	3105 INNOVATION DR STE A
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6501
Country	:	US
Telephone Number	:	407-498-0539
Fax Number	:	877-203-2038

Provider Business Practice Location Address
First Line	:	3105 INNOVATION DR STE A
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6501
Country	:	US
Telephone Number	:	407-498-0539
Fax Number	:	877-203-2038

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICANOR C. LOPEZ
Credential	:	M.D.
Telephone Number	:	267-475-8447

Provider Enumeration Date	:	11/10/2010
Last Update Date	:	11/11/2010

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