1134226699 NPI number — DR. TARA LORENCE VANBENNEKOM DO

Table of content: DR. TARA LORENCE VANBENNEKOM DO (NPI 1134226699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134226699 NPI number — DR. TARA LORENCE VANBENNEKOM DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANBENNEKOM
Provider First Name:
TARA
Provider Middle Name:
LORENCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1134226699
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 ST. JOHNS FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-824-5796
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 KINGSLEY LAKE DRIVE
Provider Second Line Business Practice Location Address:
SUITE #603
Provider Business Practice Location Address City Name:
ST. AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-824-5437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2006

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: 208000000X , with the licence number:  OS 8054 , 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: 277503400 . 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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