MEDICARE: PHYSICIANS IMMEDIATE CARE

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	332900000X	Non-Pharmacy Dispensing Site	FP0126222	FL

General Provider Information

NPI Number	:	1952572430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS IMMEDIATE CARE

Provider Business Mailing Address
First Line	:	3607 OLD CONEJO RD
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91320-2123
Country	:	US
Telephone Number	:	805-375-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	4007 SW PORT ST LUCIE BLVD
Second Line	:	SUITE #12
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-5679
Country	:	US
Telephone Number	:	772-343-1774
Fax Number	:	772-343-1744

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	KENNETH J PALESTRANT
Credential	:
Telephone Number	:	772-343-1774

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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