1851504286 NPI number — MRS. ELSIE PIERCE MILLER COTAL

Table of content: MRS. ELSIE PIERCE MILLER COTAL (NPI 1851504286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851504286 NPI number — MRS. ELSIE PIERCE MILLER COTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
ELSIE
Provider Middle Name:
PIERCE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTAL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUIZ
Provider Other First Name:
ELSIE
Provider Other Middle Name:
PIERCE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851504286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 MERIDIAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33837-3854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-421-7209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 S 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WALES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33853-4203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-679-6841
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2007

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: 224Z00000X , with the licence number:  OTA9861 , 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)





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