1487953758 NPI number — TANIA LUIZA KOERBER RD, CSP, LD/N

Table of content: TANIA LUIZA KOERBER RD, CSP, LD/N (NPI 1487953758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487953758 NPI number — TANIA LUIZA KOERBER RD, CSP, LD/N

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOERBER
Provider First Name:
TANIA
Provider Middle Name:
LUIZA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, CSP, LD/N
Provider Gender Code:
F

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:
1487953758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4270 GARDENIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-5435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-313-9193
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4270 GARDENIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-5435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-313-9193
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133VN1004X , with the licence number:  ND 3428 , 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: 020083300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com