Provider Demographics
NPI:1518268283
Name:WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC
Entity Type:Organization
Organization Name:WALK IN MEDICAL CLINIC AND FITNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICANOR
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-475-8447
Mailing Address - Street 1:3105 INNOVATION DR STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6501
Mailing Address - Country:US
Mailing Address - Phone:407-498-0539
Mailing Address - Fax:877-203-2038
Practice Address - Street 1:3105 INNOVATION DR STE A
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6501
Practice Address - Country:US
Practice Address - Phone:407-498-0539
Practice Address - Fax:877-203-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL105419261Q00000X
PAMD037726L261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0368398000OtherAMERIHEALTH
NJ550663UKEOtherMEDICARE ID-TYPE UNSPECIFIED
NJ60018874OtherHORIZON NJ HEALTH
FL001759700Medicaid
NJ5114306Medicaid
FL001759700Medicaid