1114579158 NPI number — DOCTORS DIET PROGRAM OF SOUTH FLORIDA PLLC

Table of content: (NPI 1114579158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114579158 NPI number — DOCTORS DIET PROGRAM OF SOUTH FLORIDA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS DIET PROGRAM OF SOUTH FLORIDA PLLC
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:
1114579158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3345 S DALE MABRY HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33629-7817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-839-3438
Provider Business Mailing Address Fax Number:
813-280-2258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 W REYNOLDS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33563-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-519-3438
Provider Business Practice Location Address Fax Number:
813-280-2258
Provider Enumeration Date:
07/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LOWRANCE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR OF CLINIC OPERATIONS
Authorized Official Telephone Number:
813-957-6281

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com