1184132888 NPI number — FAMILY PRACTICE ON THE GO OF FLORIDA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184132888 NPI number — FAMILY PRACTICE ON THE GO OF FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PRACTICE ON THE GO OF FLORIDA
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:
1184132888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
735 DUNLAWTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32127-9226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-808-0488
Provider Business Mailing Address Fax Number:
386-872-4232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 N NOVA RD STE 184
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-5124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-808-0488
Provider Business Practice Location Address Fax Number:
386-872-4232
Provider Enumeration Date:
01/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HEISE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
888-808-0488

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME83299 , 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)





Copyright © 2007-2025 www.npivalidator.com