1194847517 NPI number — MR. DONNA MARIE GRIFFIN MFC # 42984

Table of content: MR. DONNA MARIE GRIFFIN MFC # 42984 (NPI 1194847517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194847517 NPI number — MR. DONNA MARIE GRIFFIN MFC # 42984

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIFFIN
Provider First Name:
DONNA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MFC # 42984
Provider Gender Code:
F

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:
1194847517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FLORIDA PARK DR S STE 322
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32137-3802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-522-4111
Provider Business Mailing Address Fax Number:
386-246-2738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 FLORIDA PARK DR S STE 322
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137-3802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-522-4111
Provider Business Practice Location Address Fax Number:
386-246-2738
Provider Enumeration Date:
04/05/2007

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: 106H00000X , with the licence number:  42984 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104541400 . 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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