1417085697 NPI number — IDA WALLACE BENNETT FAMILY HEALTH CORPORATION

Table of content: (NPI 1417085697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417085697 NPI number — IDA WALLACE BENNETT FAMILY HEALTH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDA WALLACE BENNETT FAMILY HEALTH CORPORATION
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:
IDA WALLACE BENNETT FAMILY CORPORATION
Provider Other Organization Name Type Code:
4
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:
1417085697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
331 N DEERFIELD AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEERFIELD BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33441-2028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-900-6737
Provider Business Mailing Address Fax Number:
954-422-1726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 N DEERFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEERFIELD BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33441-2028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-900-6737
Provider Business Practice Location Address Fax Number:
954-422-1726
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-900-6737

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: ARNP2155102 , 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: BCBSFL . This is a "PTAN AK407" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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