1104967603 NPI number — ROCHELLE M MEAD P. T.

Table of content: ROCHELLE M MEAD P. T. (NPI 1104967603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104967603 NPI number — ROCHELLE M MEAD P. T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEAD
Provider First Name:
ROCHELLE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P. T.
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:
1104967603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
441 NW PRIMA VISTA BLVD.,
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
PORT ST. LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-873-8980
Provider Business Mailing Address Fax Number:
772-873-8981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 SOUTH 7TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-460-2520
Provider Business Practice Location Address Fax Number:
772-460-2521
Provider Enumeration Date:
02/09/2007

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: 225100000X , with the licence number:  PT18685 , 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: Y917Z . This is a "BCBS GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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