Provider Demographics
NPI:1083831192
Name:PEDIATRIC URGENT CARE GROUP OF ORMOND BEACH
Entity type:Organization
Organization Name:PEDIATRIC URGENT CARE GROUP OF ORMOND BEACH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:E
Authorized Official - Last Name:QUINTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-615-4414
Mailing Address - Street 1:1688 W GRANADA BLVD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-1851
Mailing Address - Country:US
Mailing Address - Phone:386-615-4414
Mailing Address - Fax:386-615-8466
Practice Address - Street 1:1688 W GRANADA BLVD
Practice Address - Street 2:SUITE 1A
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-1851
Practice Address - Country:US
Practice Address - Phone:386-615-4414
Practice Address - Fax:386-615-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care