Provider Demographics
NPI:1750755971
Name:TRI-CITY WALK-IN CLINIC INC
Entity type:Organization
Organization Name:TRI-CITY WALK-IN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANWAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOWDHURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-865-3997
Mailing Address - Street 1:17947 GOURD NECK LOOP
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3090
Mailing Address - Country:US
Mailing Address - Phone:850-865-3997
Mailing Address - Fax:
Practice Address - Street 1:33281 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-9008
Practice Address - Country:US
Practice Address - Phone:850-865-3997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-27
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100777173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291706800Medicaid