1669110474 NPI number — MAXCA INC

Table of content: (NPI 1669110474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669110474 NPI number — MAXCA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXCA 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:
6
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:
1669110474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5887
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34277-5887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-350-2239
Provider Business Mailing Address Fax Number:
941-870-4915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 CORTEZ RD W STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34207-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-870-7473
Provider Business Practice Location Address Fax Number:
941-870-4915
Provider Enumeration Date:
05/23/2022

Additional Information

Authorized Official

Authorized Official Last Name:
DER BOGHOSSIAN
Authorized Official First Name:
PABLO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
941-350-2239

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT13467 . This is a "FL MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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