1124224795 NPI number — PROFESSIONAL LYMPHEDEMA SERVICES INC

Table of content: (NPI 1124224795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124224795 NPI number — PROFESSIONAL LYMPHEDEMA SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL LYMPHEDEMA 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:
1124224795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 VICTORY PALM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDGEWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32141-6129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-882-1161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2568 S RIDGEWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EDGEWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32141-5980
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-423-9322
Provider Business Practice Location Address Fax Number:
386-423-9330
Provider Enumeration Date:
06/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HANAK
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-882-1161

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT11571 , 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: DE3356 . This is a "PHYSICAL THERAPY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7809762 . This is a "PHYSICAL THERAPY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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