1447689203 NPI number — CENTER FOR INDIVIDUALIZED MEDICINE AND AGE MANAGEMENT, INC

Table of content: (NPI 1447689203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447689203 NPI number — CENTER FOR INDIVIDUALIZED MEDICINE AND AGE MANAGEMENT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR INDIVIDUALIZED MEDICINE AND AGE MANAGEMENT, INC
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:
6
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:
1447689203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11616 LAKE UNDERHILL RD
Provider Second Line Business Mailing Address:
STE 205
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32825-4463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-273-7399
Provider Business Mailing Address Fax Number:
407-273-1928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11616 LAKE UNDERHILL RD
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32825-4463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-273-7399
Provider Business Practice Location Address Fax Number:
407-273-1928
Provider Enumeration Date:
11/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DONIS-RIVERA
Authorized Official First Name:
MILDRED
Authorized Official Middle Name:
Authorized Official Title or Position:
OSNER/PRESIDENT
Authorized Official Telephone Number:
407-273-7399

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME55637 , 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)





Copyright © 2007-2025 www.npivalidator.com