Provider Demographics
NPI:1710674205
Name:PEDIM OUTREACH AND SPECIALTY CLINIC LLC
Entity Type:Organization
Organization Name:PEDIM OUTREACH AND SPECIALTY CLINIC LLC
Other - Org Name:PEDIM OUTREACH INVERNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DACELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ST MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-684-8736
Mailing Address - Street 1:PO BOX 2066
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460-2066
Mailing Address - Country:US
Mailing Address - Phone:352-634-8736
Mailing Address - Fax:
Practice Address - Street 1:3565 E SUZIE LN
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-3250
Practice Address - Country:US
Practice Address - Phone:352-527-6888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty