1275520249 NPI number — ALICE M ENAULT O.T.

Table of content: ALICE M ENAULT O.T. (NPI 1275520249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275520249 NPI number — ALICE M ENAULT O.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENAULT
Provider First Name:
ALICE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAFFER
Provider Other First Name:
ALICE
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275520249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 AVENUE K. SW
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33880-3919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-297-5400
Provider Business Mailing Address Fax Number:
863-293-8230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 AVENUE K. SW
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33880-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-297-5400
Provider Business Practice Location Address Fax Number:
863-293-8230
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT8245 , 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: Z043T . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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