1013338144 NPI number — RIVIERA PLAZA MEDICAL OFFICE LLC

Table of content: (NPI 1013338144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013338144 NPI number — RIVIERA PLAZA MEDICAL OFFICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVIERA PLAZA MEDICAL OFFICE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013338144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 N HALIFAX AVE
Provider Second Line Business Mailing Address:
SUITE1
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32118-4159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-677-5415
Provider Business Mailing Address Fax Number:
386-677-1475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1702 RIDGEWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
HOLLY HILL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32117-5416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-677-5415
Provider Business Practice Location Address Fax Number:
386-677-1475
Provider Enumeration Date:
12/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MIKULA
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
HELEN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
386-677-5415

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  ME47765 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 042193600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: HS776A . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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