Provider Demographics
NPI:1194101618
Name:PRUDENTIAL URGENT CARE & DIAGNOSTIC, INC.
Entity type:Organization
Organization Name:PRUDENTIAL URGENT CARE & DIAGNOSTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-530-9280
Mailing Address - Street 1:4101 NW 3RD CT
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2857
Mailing Address - Country:US
Mailing Address - Phone:954-530-9280
Mailing Address - Fax:954-533-1024
Practice Address - Street 1:4101 NW 3RD CT
Practice Address - Street 2:SUITE 3
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2857
Practice Address - Country:US
Practice Address - Phone:954-530-9280
Practice Address - Fax:954-533-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS1505207P00000X, 261QU0200X
FLME79405208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL32023Medicare UPIN