1730665308 NPI number — NICOLE R VIGE OT

Table of content: NICOLE R VIGE OT (NPI 1730665308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730665308 NPI number — NICOLE R VIGE OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIGE
Provider First Name:
NICOLE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNERR
Provider Other First Name:
NIKI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730665308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
961 BROKEN ARROW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTONMENT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32533-3827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-238-0880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 W FAIRFIELD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32506-4111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-458-7735
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2018

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: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100434300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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