1235422775 NPI number — MD2U FLORIDA LLC

Table of content: (NPI 1235422775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235422775 NPI number — MD2U FLORIDA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD2U FLORIDA 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:
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:
1235422775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7219
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40257-0219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-416-1851
Provider Business Mailing Address Fax Number:
502-416-1857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10151 DEERWOOD PARK BLVD
Provider Second Line Business Practice Location Address:
200-250
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-0566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-327-9100
Provider Business Practice Location Address Fax Number:
502-742-3767
Provider Enumeration Date:
05/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LATTA
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CFO/CIO
Authorized Official Telephone Number:
502-416-1851

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10D2045820 . This is a "CLIA - CERTIFICATE OF WAIVER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com