Provider Demographics
NPI:1295920676
Name:QUICMED WALK IN CENTERS LLC
Entity type:Organization
Organization Name:QUICMED WALK IN CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-522-1101
Mailing Address - Street 1:11223 N WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-8350
Mailing Address - Country:US
Mailing Address - Phone:352-522-1101
Mailing Address - Fax:
Practice Address - Street 1:11223 N WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-8350
Practice Address - Country:US
Practice Address - Phone:352-522-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74735207Q00000X, 207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty