1538482740 NPI number — FLORIDA DIALYSIS CENTER OF ORLANDO LLC

Table of content: JAMIE LAUREN HANCULAK FNP (NPI 1992262729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538482740 NPI number — FLORIDA DIALYSIS CENTER OF ORLANDO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DIALYSIS CENTER OF ORLANDO 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:
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:
1538482740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 35TH ST
Provider Second Line Business Mailing Address:
UNITS 109 &110
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32839-8860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-648-9722
Provider Business Mailing Address Fax Number:
407-648-9723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 35TH ST
Provider Second Line Business Practice Location Address:
UNITS 109 & 110
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32839-8860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-648-9722
Provider Business Practice Location Address Fax Number:
407-648-9723
Provider Enumeration Date:
03/03/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BRADY
Authorized Official First Name:
SARA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CHIEF NURSING OFFICER
Authorized Official Telephone Number:
208-371-7878

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003132700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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