1710223458 NPI number — EMPOWER ME CLINICAL PRACTICE, LLC

Table of content: (NPI 1710223458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710223458 NPI number — EMPOWER ME CLINICAL PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMPOWER ME CLINICAL PRACTICE, 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:
DR. SELENA LAMOTTE, DSW
Provider Other Organization Name Type Code:
3
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:
1710223458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10568 LONGLEAF LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLINGTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33414-9398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-469-9670
Provider Business Mailing Address Fax Number:
561-634-3861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10568 LONGLEAF LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-469-9670
Provider Business Practice Location Address Fax Number:
561-634-3861
Provider Enumeration Date:
12/28/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAMOTTE
Authorized Official First Name:
SELENA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-469-9670

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW11099 , 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: 007968500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".