Basic Information
| Provider Information | |||||||||
| NPI: | 1275200784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MC MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST # MS 0445 | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792041258 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 ATLANTIC BLVD UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322252920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046418088 | ||||||||
| FaxNumber: | 9046418032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | PULLURU | ||||||||
| AuthorizedOfficialFirstName: | SOUJANYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9046418088 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.