1326349002 NPI number — ARIEL FAULKNER RD LD

Table of content: ARIEL FAULKNER RD LD (NPI 1326349002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326349002 NPI number — ARIEL FAULKNER RD LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAULKNER
Provider First Name:
ARIEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD LD
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:
1326349002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5470 MANG PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34238-5752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-825-6491
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20020 VETERANS BLVD
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33954-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-613-1790
Provider Business Practice Location Address Fax Number:
941-627-3553
Provider Enumeration Date:
11/11/2010

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: 133V00000X , with the licence number:  ND5569 , 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: N00CC . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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