1760679088 NPI number — ABA FAMILY MEDICINE, LLC

Table of content: (NPI 1760679088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760679088 NPI number — ABA FAMILY MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABA FAMILY MEDICINE, 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:
1760679088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 CLYDE MORRIS BLVD
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-8178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-676-2367
Provider Business Mailing Address Fax Number:
386-615-6402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 CLYDE MORRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-8178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-676-2367
Provider Business Practice Location Address Fax Number:
386-615-6402
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TORRES
Authorized Official First Name:
DIEGO
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
386-676-2367

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME79483 , 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: DA2451 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K4519 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00039042 . This is a "MEDICARE RAILROAD INDIVID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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