1316104292 NPI number — MR. MARK DOCUMENTO RPT

Table of content: MR. MARK DOCUMENTO RPT (NPI 1316104292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316104292 NPI number — MR. MARK DOCUMENTO RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOCUMENTO
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
M

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:
1316104292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7666
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT SAINT LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34985-7666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-408-6630
Provider Business Mailing Address Fax Number:
772-408-6750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
266 NW PEACOCK BLVD
Provider Second Line Business Practice Location Address:
SUITE 2-204 BLDG. 2
Provider Business Practice Location Address City Name:
PORT SAINT LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-2271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-408-6630
Provider Business Practice Location Address Fax Number:
772-408-6750
Provider Enumeration Date:
05/19/2008

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: 225100000X , with the licence number:  PT20821 , 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: BK828Z . This is a "PROVIDER TRANSACTION ACCESS NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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