Provider Demographics
NPI:1932453982
Name:GLADES CONVENIENT CARE CENTER INC.
Entity Type:Organization
Organization Name:GLADES CONVENIENT CARE CENTER INC.
Other - Org Name:GLADES CONVENIENT CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HARRIETT
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:863-946-1000
Mailing Address - Street 1:PO BOX 1113
Mailing Address - Street 2:51 AVENUE J, SUITE 101
Mailing Address - City:MOORE HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33471-1113
Mailing Address - Country:US
Mailing Address - Phone:863-946-1000
Mailing Address - Fax:863-946-1006
Practice Address - Street 1:51 AVENUE J.
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORE HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33471-1113
Practice Address - Country:US
Practice Address - Phone:863-946-1000
Practice Address - Fax:863-946-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS57165207Q00000X
FL9104703363A00000X
FL9101638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty