1346777067 NPI number — BRIDGETTE J KELLEY DASILVA B.S.

Table of content: BRIDGETTE J KELLEY DASILVA B.S. (NPI 1346777067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346777067 NPI number — BRIDGETTE J KELLEY DASILVA B.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY DASILVA
Provider First Name:
BRIDGETTE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLEY
Provider Other First Name:
BRIDGETTE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346777067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20345 W COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
PH 14
Provider Business Mailing Address City Name:
AVENTURA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33180-1631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-792-4931
Provider Business Mailing Address Fax Number:
305-466-2437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20345 W COUNTRY CLUB DR
Provider Second Line Business Practice Location Address:
PH 14
Provider Business Practice Location Address City Name:
AVENTURA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-1631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-792-4931
Provider Business Practice Location Address Fax Number:
305-466-2437
Provider Enumeration Date:
05/11/2017

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: 171M00000X , with the licence number:  K432070847710 , 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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