1336720291 NPI number — AMANDA MARIA REAL DE LA PAZ

Table of content: AMANDA MARIA REAL DE LA PAZ (NPI 1336720291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336720291 NPI number — AMANDA MARIA REAL DE LA PAZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REAL DE LA PAZ
Provider First Name:
AMANDA
Provider Middle Name:
MARIA
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:
1336720291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5246 CANNON WAY
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:
33415-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-560-4205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 FOREST HILL BLVD STE 3B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CLARKE SHORES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33406-6031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-506-3665
Provider Business Practice Location Address Fax Number:
561-444-2458
Provider Enumeration Date:
04/21/2021

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: 106S00000X , with the licence number:  RBT-20-136009 , 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: 109467200 . 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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