1255385167 NPI number — LEO B RAMIN PT

Table of content: LEO B RAMIN PT (NPI 1255385167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255385167 NPI number — LEO B RAMIN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAMIN
Provider First Name:
LEO
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1255385167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2813 MAGNOLIA BLOSSOM LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIANNA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32446-6395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-209-3007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951 PRIM AVE
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
GRACEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32440-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-360-5016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  PT10317 , 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: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".