1700916277 NPI number — OLGA A TROFIMOVA B.A.

Table of content: OLGA A TROFIMOVA B.A. (NPI 1700916277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700916277 NPI number — OLGA A TROFIMOVA B.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TROFIMOVA
Provider First Name:
OLGA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.A.
Provider Gender Code:
F

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:
1700916277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9052 NW 145TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33018-7335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-897-2752
Provider Business Mailing Address Fax Number:
305-274-0841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9380 SW 72ND ST STE B250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33173-5454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-274-3172
Provider Business Practice Location Address Fax Number:
305-274-0841
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 759414300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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