Provider Demographics
NPI:1376296194
Name:1ST CHOICE URGENT CARE CENTER LLC
Entity Type:Organization
Organization Name:1ST CHOICE URGENT CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-317-3214
Mailing Address - Street 1:817 NW 56TH TER STE A
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-6401
Mailing Address - Country:US
Mailing Address - Phone:352-336-0964
Mailing Address - Fax:
Practice Address - Street 1:275 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1656
Practice Address - Country:US
Practice Address - Phone:386-496-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1ST CHOICE URGENT CARE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12609OtherCLINIC LICENSE