Provider Demographics
NPI:1205943164
Name:DIANE A SCHLICK DO LLC
Entity type:Organization
Organization Name:DIANE A SCHLICK DO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHLICK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-584-5876
Mailing Address - Street 1:616 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-4115
Mailing Address - Country:US
Mailing Address - Phone:850-584-5876
Mailing Address - Fax:850-584-4939
Practice Address - Street 1:616 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-4115
Practice Address - Country:US
Practice Address - Phone:850-584-5876
Practice Address - Fax:850-584-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256619200Medicaid
FLE2588Medicare ID - Type Unspecified
FL256619200Medicaid