1093769499 NPI number — MED LIFE MEDICAL SERVICES INC

Table of content: (NPI 1093769499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093769499 NPI number — MED LIFE MEDICAL SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED LIFE MEDICAL SERVICES INC
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:
1093769499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8260 W FLAGLER ST
Provider Second Line Business Mailing Address:
SUITE 2-M
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33144-2069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-534-2584
Provider Business Mailing Address Fax Number:
786-542-0676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8260 W FLAGLER ST
Provider Second Line Business Practice Location Address:
SUITE 2-M
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33144-2069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-534-2584
Provider Business Practice Location Address Fax Number:
786-542-0676
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACOMINO
Authorized Official First Name:
LESMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
786-580-3897

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102179001 . 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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