1366631061 NPI number — MEDERI CARETENDERS VS OF TAMPA, LLC

Table of content: DR. LISA MARIE SHEEHAN M.D. (NPI 1518146059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366631061 NPI number — MEDERI CARETENDERS VS OF TAMPA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDERI CARETENDERS VS OF TAMPA, LLC
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:
1366631061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 HUGH WALLIS RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-2511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:
337-443-4154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1413 TECH BLVD STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33619-7822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-282-8520
Provider Business Practice Location Address Fax Number:
813-282-8530
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PROFFITT
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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