Provider Demographics
NPI:1063808301
Name:PHYSICIANS IMMEDIATE CARE SOUTHWEST, LLC
Entity type:Organization
Organization Name:PHYSICIANS IMMEDIATE CARE SOUTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PALESTRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-343-1776
Mailing Address - Street 1:4007 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5679
Mailing Address - Country:US
Mailing Address - Phone:772-343-1774
Mailing Address - Fax:772-343-1744
Practice Address - Street 1:4007 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5679
Practice Address - Country:US
Practice Address - Phone:772-343-1774
Practice Address - Fax:772-343-1744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS IMMEDIATE CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5630261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care