1518922947 NPI number — LAKEWOOD RANCH PRIMARY CARE LLC

Table of content: (NPI 1518922947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518922947 NPI number — LAKEWOOD RANCH PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWOOD RANCH PRIMARY CARE 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:
1518922947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8340 LAKEWOOD RANCH BLVD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
LAKEWOOD RANCH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34202-5180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-907-0588
Provider Business Mailing Address Fax Number:
941-373-6622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8340 LAKEWOOD RANCH BLVD
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
LAKEWOOD RANCH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34202-5180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-907-0588
Provider Business Practice Location Address Fax Number:
941-373-6622
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MISHNER
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
941-907-0588

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34586 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DA1812 . This is a "MCR RR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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