1053838946 NPI number — ACE MEDICAL LLC

Table of content: (NPI 1053838946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053838946 NPI number — ACE MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACE MEDICAL 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:
1053838946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9471 BAYMEADOWS RD STE 405
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-7937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-238-3752
Provider Business Mailing Address Fax Number:
904-513-9250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 W HIGHLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INVERNESS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34452-4819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-475-2039
Provider Business Practice Location Address Fax Number:
904-330-0668
Provider Enumeration Date:
08/23/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CORDERO
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
904-238-3752

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7635710001 . This is a "NSC" identifier . This identifiers is of the category "OTHER".




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