1366803322 NPI number — COCONUT CREEK PROFESSIONAL GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366803322 NPI number — COCONUT CREEK PROFESSIONAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COCONUT CREEK PROFESSIONAL GROUP 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:
1366803322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3880 COCONUT CREEK PKWY STE 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COCONUT CREEK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33066-1651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-657-8524
Provider Business Mailing Address Fax Number:
954-301-0794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3880 COCONUT CREEK PKWY STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COCONUT CREEK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33066-1651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-657-8524
Provider Business Practice Location Address Fax Number:
954-301-0794
Provider Enumeration Date:
03/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
REUL
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-657-8524

Provider Taxonomy Codes

  • Taxonomy code: 2084P0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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