1235752460 NPI number — WHEAT L L C

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 1235752460 NPI number — WHEAT L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHEAT L L C
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:
1235752460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2627 NE 203RD ST STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33180-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-528-2836
Provider Business Mailing Address Fax Number:
305-682-8994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2627 NE 203RD ST STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-528-2836
Provider Business Practice Location Address Fax Number:
305-682-8994
Provider Enumeration Date:
05/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
REGINA
Authorized Official Middle Name:
F
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
305-528-2836

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10D2181154 . This is a "CLIA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: E063187 . This is a "INSURANCE 2-15" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6011757 . This is a "HEALTH CARE CLINIC ESTABLSHMENT" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 13-64-202-7797 . This is a "BIOMEDICAL WASTE CLINICAL LABORATORY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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