1134417124 NPI number — KEY WEST FAMILY PRACTICE, PLLC

Table of content: (NPI 1134417124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134417124 NPI number — KEY WEST FAMILY PRACTICE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEY WEST FAMILY PRACTICE, 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:
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:
1134417124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3420 DUCK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEY WEST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33040-4427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-296-5358
Provider Business Mailing Address Fax Number:
305-293-1146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3420 DUCK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEY WEST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33040-4427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-296-5358
Provider Business Practice Location Address Fax Number:
305-293-1146
Provider Enumeration Date:
07/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HOYT
Authorized Official First Name:
RABECCA
Authorized Official Middle Name:
ASHLEY
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
305-296-5358

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AP922 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MA25088 , 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: C0426 . This is a "FL BLUE MASSAGE ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: E7R4I . This is a "FL BLUE GROUP ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117213100 . 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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