1245265800 NPI number — PRO2 LAKE CITY, LLC

Table of content: (NPI 1245265800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245265800 NPI number — PRO2 LAKE CITY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO2 LAKE CITY, 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:
1245265800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4550 SW 41ST BLVD
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32608-4255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-755-9511
Provider Business Mailing Address Fax Number:
386-755-9577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4550 SW 41ST BLVD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-755-9511
Provider Business Practice Location Address Fax Number:
386-755-9577
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
513-469-5771

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  1312130 , 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: 031183900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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