1942481759 NPI number — MEDERI CARETENDERS VS OF SW FL, LLC

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 1942481759 NPI number — MEDERI CARETENDERS VS OF SW FL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDERI CARETENDERS VS OF SW FL, 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:
6
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:
1942481759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:
337-443-4154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6150 DIAMOND CENTRE CT UNIT 600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-7147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-481-5999
Provider Business Practice Location Address Fax Number:
239-481-5522
Provider Enumeration Date:
11/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GACHASSIN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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