1689053324 NPI number — CHOICE ONE MEDICAL ASSOCIATES, LLC

Table of content: (NPI 1689053324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689053324 NPI number — CHOICE ONE MEDICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE ONE MEDICAL ASSOCIATES, 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:
1689053324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49 N FEDERAL HWY
Provider Second Line Business Mailing Address:
STE 135
Provider Business Mailing Address City Name:
POMPANO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33062-4304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-703-6065
Provider Business Mailing Address Fax Number:
888-972-1875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9730 NE 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI SHORES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33138-2311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-758-7979
Provider Business Practice Location Address Fax Number:
305-758-0034
Provider Enumeration Date:
05/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
MARY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
561-389-9568

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME 58497 , 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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