1942806260 NPI number — REDTAG-19, LLC

Table of content: (NPI 1942806260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942806260 NPI number — REDTAG-19, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REDTAG-19, 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:
RED TAG-19 LLC
Provider Other Organization Name Type Code:
4
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:
1942806260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8765 WATERCREST CIR E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33076-2853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-482-3740
Provider Business Mailing Address Fax Number:
719-245-1341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8765 WATERCREST CIR E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33076-2853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-482-3740
Provider Business Practice Location Address Fax Number:
719-245-1341
Provider Enumeration Date:
12/10/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHINTRE
Authorized Official First Name:
LATA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/FOUNDER
Authorized Official Telephone Number:
954-482-3740

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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