1386178739 NPI number — THE CHILDRENS DOCTOR OF TAMPABAY, JACQUELIN ENIEBLES MD, PLLC

Table of content: (NPI 1386178739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386178739 NPI number — THE CHILDRENS DOCTOR OF TAMPABAY, JACQUELIN ENIEBLES MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CHILDRENS DOCTOR OF TAMPABAY, JACQUELIN ENIEBLES MD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1386178739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1375 INDIAN TRAILS NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-481-8075
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14499 NORTH DALE MABRY HWY, SUITE 180-S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-481-8075
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NIEBLES
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
MARIA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
727-481-8075

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME66997 , 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: 020637800 . 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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