1083862262 NPI number — GERALDINE JUNE SLAICK CRNA

Table of content: GERALDINE JUNE SLAICK CRNA (NPI 1083862262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083862262 NPI number — GERALDINE JUNE SLAICK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLAICK
Provider First Name:
GERALDINE
Provider Middle Name:
JUNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1083862262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 NW 132ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-845-9667
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 W CYPRESS CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33309-1730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-933-0377
Provider Business Practice Location Address Fax Number:
954-933-0367
Provider Enumeration Date:
08/30/2008

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: 163W00000X , with the licence number:  ARNP 3124012 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 079012 , 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: 105607300 . 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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