1639769276 NPI number — MY ABA FAMILY 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 1639769276 NPI number — MY ABA FAMILY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY ABA FAMILY 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:
1639769276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10308 BROWNWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32825-6628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-228-7577
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
238 WILSHIRE BLVD STE 155
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASSELBERRY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32707-5362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-510-9325
Provider Business Practice Location Address Fax Number:
407-704-2556
Provider Enumeration Date:
01/18/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BERMUDEZ VILLA
Authorized Official First Name:
YANKO
Authorized Official Middle Name:
Authorized Official Title or Position:
AMBR
Authorized Official Telephone Number:
203-510-9325

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109283000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".