1285053553 NPI number — ENRICHMENT SUPPORT SERVICES, LLC

Table of content: (NPI 1285053553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285053553 NPI number — ENRICHMENT SUPPORT SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENRICHMENT SUPPORT SERVICES, 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:
1285053553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 ONYX RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33025-2821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-257-7394
Provider Business Mailing Address Fax Number:
954-251-0562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 PROMENADE DR
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33026-6034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-364-8842
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DANIEL
Authorized Official First Name:
ANSE
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
954-257-7394

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  L14000040502 , 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: 014869100 . 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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