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

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 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:
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:
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".




Copyright © 2007-2025 www.npivalidator.com