1821372129 NPI number — CYPRESS CREEK MEDICAL SPA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821372129 NPI number — CYPRESS CREEK MEDICAL SPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CYPRESS CREEK MEDICAL SPA
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:
1821372129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26827 FOGGY CREEK RD
Provider Second Line Business Mailing Address:
SUITE 101A
Provider Business Mailing Address City Name:
WESLEY CHAPEL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33544-6768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-973-7774
Provider Business Mailing Address Fax Number:
813-973-8882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1942 HIGHLAND OAKS BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LUTZ
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33559-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-948-3838
Provider Business Practice Location Address Fax Number:
813-949-0629
Provider Enumeration Date:
10/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ROSEQUIST
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
813-948-3838

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0040424 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 0048283 , 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: 34555 . This is a "BLUE CROSS BLUE SHIELD OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CN4592 . This is a "RAILROAD RETIREMENT" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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