1417294158 NPI number — FLORIDA NERVE MED LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417294158 NPI number — FLORIDA NERVE MED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA NERVE MED 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:
1417294158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
741 DUCHESS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-1553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-602-6191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8198 S JOG RD
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33472-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-602-6191
Provider Business Practice Location Address Fax Number:
561-429-3630
Provider Enumeration Date:
01/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GEISSE
Authorized Official First Name:
HILDEGARDE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-310-7759

Provider Taxonomy Codes

  • Taxonomy code: 2084N0600X , with the licence number:  ME96190 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0008X , with the licence number: ME96190 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204R00000X , with the licence number: ME96190 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: ME96190 , 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: ME96190 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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