1215190459 NPI number — RECTAL RELIEF CENTER

Table of content: (NPI 1215190459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215190459 NPI number — RECTAL RELIEF CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RECTAL RELIEF CENTER
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:
1215190459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13005 SOUTHERN BLVD STE 122
Provider Second Line Business Mailing Address:
SUITE 122 MEDICAL MALL ONE
Provider Business Mailing Address City Name:
LOXAHATCHEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33470-9231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-842-5050
Provider Business Mailing Address Fax Number:
561-793-9989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13005 SOUTHERN BLVD STE 122
Provider Second Line Business Practice Location Address:
SUITE 122 MEDICAL MALL ONE
Provider Business Practice Location Address City Name:
LOXAHATCHEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33470-9231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-842-5050
Provider Business Practice Location Address Fax Number:
561-793-9989
Provider Enumeration Date:
07/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GRISSO
Authorized Official First Name:
SHERI
Authorized Official Middle Name:
SHANNON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-842-5050

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP3357122 , 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: 011857700 . 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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