Provider Demographics
NPI:1104247865
Name:EXPRESS CARE CLINIC LLC
Entity type:Organization
Organization Name:EXPRESS CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLEKSANDR
Authorized Official - Middle Name:V
Authorized Official - Last Name:ONUSHKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-475-3367
Mailing Address - Street 1:2650 STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779
Mailing Address - Country:US
Mailing Address - Phone:407-475-3366
Mailing Address - Fax:407-475-3367
Practice Address - Street 1:2650 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4815
Practice Address - Country:US
Practice Address - Phone:407-475-3366
Practice Address - Fax:407-475-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X, 207QG0300X, 2083S0010X, 207PS0010X, 261QR0200X, 261QU0200X
FL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care