1275067555 NPI number — AENDIRA MEDICAL LLC

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 1275067555 NPI number — AENDIRA MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AENDIRA MEDICAL 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:
1275067555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1675 HANCOCK RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34711-7667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 HANCOCK RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-978-0722
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
ADRIANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
352-432-9990

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101677100 . 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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