1639514607 NPI number — ELEVATION HEALTH LAKE MARY,LLC

Table of content: JONATHAN PAUL SAMAHA PA-C (NPI 1881029965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639514607 NPI number — ELEVATION HEALTH LAKE MARY,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATION HEALTH LAKE MARY,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:
1639514607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7948 DAVIS BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH RICHLAND HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76182-6954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-697-2560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3621 LAKE EMMA RD # 121
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-6199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-333-2277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ROLLINS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
305-710-4868

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH7458 , 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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