1104143486 NPI number — VIP AMERICA OF SOUTHWEST FLORIDA, LLC

Table of content: (NPI 1104143486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104143486 NPI number — VIP AMERICA OF SOUTHWEST FLORIDA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIP AMERICA OF SOUTHWEST FLORIDA, 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:
1104143486
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 S KANNER HWY
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34994-4600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-220-6005
Provider Business Mailing Address Fax Number:
772-220-5867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14421 METROPOLIS AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-4323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-690-9969
Provider Business Practice Location Address Fax Number:
239-690-9971
Provider Enumeration Date:
04/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BALL
Authorized Official First Name:
JILL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-220-6005

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  NR30211194 , 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: 676037604 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114309400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com