Provider Demographics
NPI:1730405820
Name:MEDFAST URGENT CARE CENTERS, LLC
Entity type:Organization
Organization Name:MEDFAST URGENT CARE CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-633-8620
Mailing Address - Street 1:7925 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8211
Mailing Address - Country:US
Mailing Address - Phone:321-751-7222
Mailing Address - Fax:321-751-6655
Practice Address - Street 1:5005 PORT ST JOHN PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4305
Practice Address - Country:US
Practice Address - Phone:321-751-7222
Practice Address - Fax:321-751-6655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDFAST URGENT CARE CENTERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-14
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6588261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF73089Medicare UPIN