1013375195 NPI number — DUVAL VASCULAR CENTER, LLC

Table of content: NORA MAE MESA LMSW (NPI 1255897013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013375195 NPI number — DUVAL VASCULAR CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUVAL VASCULAR CENTER, 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:
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:
1013375195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 PALM HARBOR BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34683-1930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-474-0090
Provider Business Mailing Address Fax Number:
727-474-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 W MONROE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-1177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-518-1398
Provider Business Practice Location Address Fax Number:
904-513-0231
Provider Enumeration Date:
02/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DEES
Authorized Official First Name:
JANET
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
727-474-0090

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018708300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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