1366957482 NPI number — VENTURE MEDICAL OF FLORIDA LLC

Table of content: (NPI 1366957482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366957482 NPI number — VENTURE MEDICAL OF FLORIDA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VENTURE MEDICAL OF FLORIDA 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:
ELLENTON URGENT CARE
Provider Other Organization Name Type Code:
3
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:
1366957482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7206 16TH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34209-1151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 8TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMETTO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34221-5120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-544-0366
Provider Business Practice Location Address Fax Number:
941-212-6059
Provider Enumeration Date:
12/12/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETREAS
Authorized Official First Name:
ALEXANDER
Authorized Official Middle Name:
N
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
941-400-7051

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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