Provider Demographics
NPI:1598047698
Name:ADVANCED HEALTHCARE CLINIC, LLC
Entity Type:Organization
Organization Name:ADVANCED HEALTHCARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBE
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:941-351-4949
Mailing Address - Street 1:9114 TOWN CENTER PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5054
Mailing Address - Country:US
Mailing Address - Phone:941-351-4949
Mailing Address - Fax:941-351-3033
Practice Address - Street 1:9114 TOWN CENTER PKWY
Practice Address - Street 2:STE 101
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-5053
Practice Address - Country:US
Practice Address - Phone:941-351-4949
Practice Address - Fax:941-351-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2931171100000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty