1154456622 NPI number — MIGUN OF THE TREASURE COAST L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154456622 NPI number — MIGUN OF THE TREASURE COAST L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIGUN OF THE TREASURE COAST L.L.C.
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:
1154456622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2311 N W FEDERAL HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-921-6659
Provider Business Mailing Address Fax Number:
772-692-2384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2311 NW FEDERAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-9311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-921-6659
Provider Business Practice Location Address Fax Number:
772-692-2384
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
JACK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-921-6659

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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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