1245788595 NPI number — BANANA WIND MEDICAL GROUP, L.L.C

Table of content: (NPI 1245788595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245788595 NPI number — BANANA WIND MEDICAL GROUP, L.L.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANANA WIND MEDICAL GROUP, 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:
DYNAMIK HEALTH CARE
Provider Other Organization Name Type Code:
3
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:
1245788595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 W PINE ST
Provider Second Line Business Mailing Address:
SUITE 218
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32801-2610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-259-8731
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11335 COMMERCIAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32836-6216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-259-8731
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SHAVER
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
DIRECTOR OF NURSING
Authorized Official Telephone Number:
321-315-3601

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  RN9246384 , 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)





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