1689672602 NPI number — PERSONAL FAMILY HEALTH CARE

Table of content: TIMOTHY ONEAL BROADDRICK DC (NPI 1417038316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689672602 NPI number — PERSONAL FAMILY HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERSONAL FAMILY HEALTH CARE
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:
1689672602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
391 LEE BLVD
Provider Second Line Business Mailing Address:
400
Provider Business Mailing Address City Name:
LEHIGH ACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33936-4973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-369-2226
Provider Business Mailing Address Fax Number:
239-369-5820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 LEE BLVD
Provider Second Line Business Practice Location Address:
400
Provider Business Practice Location Address City Name:
LEHIGH ACRES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33936-4973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-369-2226
Provider Business Practice Location Address Fax Number:
239-369-5820
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TORO
Authorized Official First Name:
ELMER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-369-2226

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME87058 , 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: 266565400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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