1629063623 NPI number — A-1 MASTECTOMY CARE, INC

Table of content: (NPI 1629063623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629063623 NPI number — A-1 MASTECTOMY CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A-1 MASTECTOMY CARE, 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:
1629063623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16608 SADDLE CLUB RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33326-1808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-515-0740
Provider Business Mailing Address Fax Number:
954-515-0260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16608 SADDLE CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33326-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-515-0740
Provider Business Practice Location Address Fax Number:
954-515-0260
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WISEMAN
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-515-0740

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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: 296732 . This is a "AVMED DME PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002X6 . This is a "PREFERRED HEALTH PARTNERS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0-50342 . This is a "NEIGHBORHOOD DME PROVIDE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7565570 . This is a "AETNA PPO PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3647669 . This is a "AETNA HMO PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: R9553 . This is a "BLUE CROSS BLUE SHIELD DM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 245123 . This is a "WELLCARE DME PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 118315400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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