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NPI Code Detail

MEDICARE: SANDESTIN URGENT CARE, LLC

MEDICARE: SANDESTIN URGENT CARE, 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
1261Q00000XClinic/Center

General Provider Information

NPI Number : 1922341817
Entity Type Code : Organization
Provider Name (Legal Business Name) : SANDESTIN URGENT CARE, LLC
Provider Business Mailing Address
First Line : 15000 EMERALD COAST PKWY
Second Line :
City : DESTIN
State : FL
Zip : 32541-3338
Country : US
Telephone Number : 850-337-5174
Fax Number :
Provider Business Practice Location Address
First Line : 400 AUDUBON DR
Second Line :
City : MIRAMAR BEACH
State : FL
Zip : 32550-4594
Country : US
Telephone Number : 850-267-6767
Fax Number :
Authorized Official
Title or Position : CFO
Name : MR. JAMES CHARLES KOUTSKY
Credential :
Telephone Number : 850-337-5174
Provider Enumeration Date : 03/29/2013
Last Update Date : 03/26/2014

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