1598148678 NPI number — RENAMED LLC

Table of content: (NPI 1598148678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598148678 NPI number — RENAMED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAMED 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:
1598148678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31966
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:
33420-1966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-676-0566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 JUPITER LAKES BLVD STE 3201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458-7189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-948-3331
Provider Business Practice Location Address Fax Number:
561-208-5810
Provider Enumeration Date:
07/07/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALMAKKEE
Authorized Official First Name:
AMMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
561-676-0566

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 88718 , 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: 113923000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".