1124020656 NPI number — TRI COUNTY PET LLC

Table of content: (NPI 1124020656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124020656 NPI number — TRI COUNTY PET LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI COUNTY PET 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:
6
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:
1124020656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 N 35TH AVE
Provider Second Line Business Mailing Address:
SUITE 665
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-5424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-981-6668
Provider Business Mailing Address Fax Number:
954-981-5944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 N 35TH AVE
Provider Second Line Business Practice Location Address:
SUITE 665
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-5424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-981-6668
Provider Business Practice Location Address Fax Number:
954-981-5944
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ-DENO
Authorized Official First Name:
LISETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
954-981-6668

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  HCC5507 , 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: 003906000 . 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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