1184277196 NPI number — JUSTINA LAROSE OLAZABAL

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 1184277196 NPI number — JUSTINA LAROSE OLAZABAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLAZABAL
Provider First Name:
JUSTINA
Provider Middle Name:
LAROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1184277196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GUIDEWELL, 4855 TOWN CENTER PARKWAY,
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:
32246-8437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-363-5880
Provider Business Mailing Address Fax Number:
904-928-4290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 N CONGRESS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33426-8209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-374-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2019

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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