1285956037 NPI number — EDC OF VOLUSIA, LLC

Table of content: (NPI 1285956037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285956037 NPI number — EDC OF VOLUSIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDC OF VOLUSIA, 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:
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:
1285956037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 N DIXIE FWY
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
NEW SMYRNA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32168-6201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-423-0505
Provider Business Mailing Address Fax Number:
386-423-0515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 DUNLAWTON AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-322-6111
Provider Business Practice Location Address Fax Number:
386-322-3777
Provider Enumeration Date:
02/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RHO
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-322-6111

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  ME98466 , 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)