1235148578 NPI number — PET LLC

Table of content: (NPI 1235148578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235148578 NPI number — PET LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PET LLC
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:
1235148578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5149 N 9TH AVE STE 124
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504-8779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-478-6336
Provider Business Mailing Address Fax Number:
850-478-6361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5149 N 9TH AVE
Provider Second Line Business Practice Location Address:
STE 124
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-8756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-478-6336
Provider Business Practice Location Address Fax Number:
850-478-6361
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLLITT
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
850-478-6336

Provider Taxonomy Codes

  • Taxonomy code: 2085N0904X , with the licence number:  3670 1 , 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: P00274147 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2974 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: G0905 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 109430800 . 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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