1275163461 NPI number — LCB PHYSICIANS, PLLC

Table of content: (NPI 1275163461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275163461 NPI number — LCB PHYSICIANS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LCB PHYSICIANS, PLLC
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:
1275163461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1648 TAYLOR RD # 606
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32128-6753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-313-8013
Provider Business Mailing Address Fax Number:
386-703-2304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 PALMETTO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW SMYRNA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32168-7323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-267-6224
Provider Business Practice Location Address Fax Number:
386-703-2304
Provider Enumeration Date:
01/16/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLAUM
Authorized Official First Name:
LOUIS
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
813-313-8013

Provider Taxonomy Codes

  • Taxonomy code: 2086S0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117225600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".