1720325517 NPI number — DISTRICT CLINIC HOLDINGS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720325517 NPI number — DISTRICT CLINIC HOLDINGS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISTRICT CLINIC HOLDINGS INC
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:
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:
1720325517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 N FLAGLER DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BCH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33401-3429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-659-1270
Provider Business Mailing Address Fax Number:
561-833-9469

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 SOUTHWINDS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANTANA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-582-5559
Provider Business Practice Location Address Fax Number:
561-439-4384
Provider Enumeration Date:
01/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
DARCY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
561-804-5885

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008037100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008037101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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