1649444332 NPI number — JO ELLEN TOMLINSON OD LLC

Table of content: (NPI 1649444332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649444332 NPI number — JO ELLEN TOMLINSON OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JO ELLEN TOMLINSON OD 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:
1649444332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32580-0416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-892-4022
Provider Business Mailing Address Fax Number:
850-892-3975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1226 FREEPORT HWY S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEFUNIAK SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32435-3396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-892-4022
Provider Business Practice Location Address Fax Number:
850-892-3975
Provider Enumeration Date:
04/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TOMLINSON
Authorized Official First Name:
JO
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-892-4022

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC2567 , 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: 20416 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 620133400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".