1548545601 NPI number — PRACTITIONER MEDICAL SERVICES INC

Table of content: (NPI 1548545601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548545601 NPI number — PRACTITIONER MEDICAL SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRACTITIONER MEDICAL SERVICES 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:
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:
1548545601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22274 SW 61ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33428-4410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-843-2325
Provider Business Mailing Address Fax Number:
561-483-6266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3075 NW 35TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUDERDALE LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33311-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-843-2325
Provider Business Practice Location Address Fax Number:
561-483-6266
Provider Enumeration Date:
10/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CARNER
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-843-2325

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  P11000009589 , 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)





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