MEDICARE: 1ST CHOICE URGENT CARE 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
2	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14177	OTHER	FL	CLINIC LICENSE

General Provider Information

NPI Number	:	1588317309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1ST CHOICE URGENT CARE CENTER LLC

Provider Business Mailing Address
First Line	:	817 NW 56TH TER STE A
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32605-6401
Country	:	US
Telephone Number	:	352-336-0964
Fax Number	:

Provider Business Practice Location Address
First Line	:	817 NW 56TH TER STE B
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32605-6401
Country	:	US
Telephone Number	:	352-336-0964
Fax Number	:

Authorized Official
Title or Position	:	CONSULTANT
Name	:	JOHN DISTEFANO
Credential	:
Telephone Number	:	352-317-3214

Provider Enumeration Date	:	02/01/2022
Last Update Date	:	02/01/2022

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