1396978656 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Table of content: (NPI 1396978656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396978656 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
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:
6
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:
1396978656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 LAKE LUCIEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-875-2080
Provider Business Mailing Address Fax Number:
407-875-0518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7310 COLLEGE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-5503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-540-9660
Provider Business Practice Location Address Fax Number:
407-875-0518
Provider Enumeration Date:
09/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LOGAN
Authorized Official First Name:
NEFRITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER SERVICE REP
Authorized Official Telephone Number:
407-875-2080

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , 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)





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