1285387332 NPI number — MARIE NAOMI C FORGES MADISTIN

Table of content: MARIE NAOMI C FORGES MADISTIN (NPI 1285387332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285387332 NPI number — MARIE NAOMI C FORGES MADISTIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORGES MADISTIN
Provider First Name:
MARIE NAOMI
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1285387332
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 CLEMATIS ST STE 5-531
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33401-5107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-671-4036
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38754 STATE ROAD 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLE GLADE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33430-5615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-983-9220
Provider Business Practice Location Address Fax Number:
561-983-9320
Provider Enumeration Date:
01/29/2022

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: 363LF0000X , with the licence number:  APRN11017807 , 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: 113643500 . 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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