1639514607 NPI number — ELEVATION HEALTH LAKE MARY,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 1639514607 NPI number — ELEVATION HEALTH LAKE MARY,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATION HEALTH LAKE MARY,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:
1639514607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7948 DAVIS BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH RICHLAND HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76182-6954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-697-2560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3621 LAKE EMMA RD # 121
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-6199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-333-2277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ROLLINS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
305-710-4868

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH7458 , 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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