1295747806 NPI number — PRUDENCIO E. LAROYA, M.D. PA

Table of content: (NPI 1295747806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295747806 NPI number — PRUDENCIO E. LAROYA, M.D. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRUDENCIO E. LAROYA, M.D. PA
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:
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:
1295747806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 S 23RD ST
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34950-4830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-466-2045
Provider Business Mailing Address Fax Number:
772-466-8646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 S 23RD ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34950-4830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-466-2045
Provider Business Practice Location Address Fax Number:
772-466-8646
Provider Enumeration Date:
08/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAROYA
Authorized Official First Name:
PRUDENCIO
Authorized Official Middle Name:
ESTOLERO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
772-466-2045

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 069288300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000366600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003471100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".