1164805016 NPI number — BENZER FL 3 LLC

Table of content: NICOLE ALISON COSTELLO PHARMD (NPI 1164854170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164805016 NPI number — BENZER FL 3 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENZER FL 3 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:
6
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:
1164805016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 W INDIATOWN ROAD
Provider Second Line Business Mailing Address:
BAY 23
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-529-2851
Provider Business Mailing Address Fax Number:
561-529-2874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 W INDIATOWN ROAD
Provider Second Line Business Practice Location Address:
BAY 23
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-529-2851
Provider Business Practice Location Address Fax Number:
561-529-2874
Provider Enumeration Date:
07/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
TEJAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
561-529-2851

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH29220 , 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: 102220000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2152983 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 015846400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102220000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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