1295057776 NPI number — ANGIE LISSETTE BOLANOS-ESCALONA OTR

Table of content: ANGIE LISSETTE BOLANOS-ESCALONA OTR (NPI 1295057776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295057776 NPI number — ANGIE LISSETTE BOLANOS-ESCALONA OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLANOS-ESCALONA
Provider First Name:
ANGIE
Provider Middle Name:
LISSETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1295057776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15751 SHERIDAN ST
Provider Second Line Business Mailing Address:
STE 162
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33331-3486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-348-6361
Provider Business Mailing Address Fax Number:
866-665-8671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 E 4TH AVE
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33010-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-348-6361
Provider Business Practice Location Address Fax Number:
866-665-8671
Provider Enumeration Date:
02/24/2010

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:  9463 , 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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