1932514254 NPI number — MRS. TRACENA ANNETTE STUDMIRE HOME HEALTH

Table of content: MR. JASON MENDOZA PT (NPI 1578507406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932514254 NPI number — MRS. TRACENA ANNETTE STUDMIRE HOME HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUDMIRE
Provider First Name:
TRACENA
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
HOME HEALTH
Provider Gender Code:
F

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:
1932514254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12513 WISCONSIN WOODS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32824-9022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-682-6819
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
351 DELANCEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33837-7644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-682-6819
Provider Business Practice Location Address Fax Number:
407-870-9605
Provider Enumeration Date:
06/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TA0700X , with the licence number:  005538400 , 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: 005538400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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