Provider Demographics
NPI:1033193743
Name:MEMORIAL URGENT CARE MANDARIN LLC
Entity Type:Organization
Organization Name:MEMORIAL URGENT CARE MANDARIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-2117
Mailing Address - Street 1:11701-32 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1884
Mailing Address - Country:US
Mailing Address - Phone:904-996-7600
Mailing Address - Fax:904-306-8065
Practice Address - Street 1:11701 SAN JOSE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-0756
Practice Address - Country:US
Practice Address - Phone:904-306-8060
Practice Address - Fax:904-306-8065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE3436Medicare PIN
K8653Medicare PIN