1073762431 NPI number — REMWAY PORT ST LUCIE, 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 1073762431 NPI number — REMWAY PORT ST LUCIE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REMWAY PORT ST LUCIE, 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:
1073762431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 NW LAKE WHITNEY PL
Provider Second Line Business Mailing Address:
SUITE 102 BLDG P
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34986-1605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-323-2661
Provider Business Mailing Address Fax Number:
772-323-2666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 NW LAKE WHITNEY PL
Provider Second Line Business Practice Location Address:
SUITE 102 BLDG P
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-323-2661
Provider Business Practice Location Address Fax Number:
772-323-2666
Provider Enumeration Date:
09/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MAHABIR-HERRERA
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
MARTINA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
772-323-2661

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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