1932282167 NPI number — LIVE OAK FOOT & ANKLE

Table of content: (NPI 1932282167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932282167 NPI number — LIVE OAK FOOT & ANKLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVE OAK FOOT & ANKLE
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:
1932282167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17820 SE 109TH AVE
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
SUMMERFIELD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-347-3338
Provider Business Mailing Address Fax Number:
352-347-3389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17820 SE 109TH AVE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
SUMMERFIELD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-347-3338
Provider Business Practice Location Address Fax Number:
352-347-3389
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EFFREN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
352-347-3338

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 011016000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com