1417589771 NPI number — URGENT CARE CENTERS OF BREVARD COUNTY LLC

Table of content: (NPI 1417589771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417589771 NPI number — URGENT CARE CENTERS OF BREVARD COUNTY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URGENT CARE CENTERS OF BREVARD COUNTY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417589771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 WESTHALL LN STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-200-2300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 MALABAR RD NE
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
MALABAR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-200-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BRADY
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-200-2300

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105815703 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: MQ224 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: EM4AN . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 105815703 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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