Provider Demographics
NPI:1588856306
Name:MJS IRRV COMPLEX TRUST
Entity Type:Organization
Organization Name:MJS IRRV COMPLEX TRUST
Other - Org Name:FAIRMOUNT WALK-IN MED CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/TRUSTEE
Authorized Official - Prefix:DR
Authorized Official - First Name:CIRILO
Authorized Official - Middle Name:M
Authorized Official - Last Name:SERALDE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:863-382-4949
Mailing Address - Street 1:3750 US 27 N.
Mailing Address - Street 2:SUITE 4-F
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-1690
Mailing Address - Country:US
Mailing Address - Phone:863-382-4949
Mailing Address - Fax:863-382-3811
Practice Address - Street 1:3750 US 27 N.
Practice Address - Street 2:SUITE 4-F
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1690
Practice Address - Country:US
Practice Address - Phone:863-382-4949
Practice Address - Fax:863-382-3811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043253261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21429OtherVICTOR M SERALDE MCR UPIN
FL41214COtherMEDICARE PROVIDER CIRILO SERALDE FOR FAIRMOUNT CLINIC
FLK2401OtherMEDICARE PART B GROUP PROVIDER
FL28115AOtherVICTOR SERALDE PROVIDER NUMBER FOR FAIRMOUNT CLINIC
10D0293128OtherCLIA GROUP NUMBER
FL54734OtherCIRILO M SERALDE MCR UPIN
FL259715200OtherMEDIPASS PROVIDER NUMBER GROUP