1104492123 NPI number — FLORIDA WOMAN CARE, LLC

Table of content: (NPI 1104492123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104492123 NPI number — FLORIDA WOMAN CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA WOMAN CARE, 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:
1104492123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-9100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-300-2410
Provider Business Mailing Address Fax Number:
561-235-7292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3155 NW 82ND AVE STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33122-1056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-226-5651
Provider Business Practice Location Address Fax Number:
305-226-2424
Provider Enumeration Date:
06/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
ERICA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
561-300-2410

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020958359 . 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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