Provider Demographics
NPI:1265863765
Name:CONQUEST CLINICS LLC
Entity Type:Organization
Organization Name:CONQUEST CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:VANLANDINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-544-2962
Mailing Address - Street 1:1408 N PIEDMONT WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7974
Mailing Address - Country:US
Mailing Address - Phone:727-692-6197
Mailing Address - Fax:
Practice Address - Street 1:1408 N PIEDMONT WAY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7974
Practice Address - Country:US
Practice Address - Phone:727-692-6197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy