1780222315 NPI number — KARMELITA FAZLOVIC CBHCMS

Table of content: KARMELITA FAZLOVIC CBHCMS (NPI 1780222315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780222315 NPI number — KARMELITA FAZLOVIC CBHCMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAZLOVIC
Provider First Name:
KARMELITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CBHCMS
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:
1780222315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2831 RINGLING BLVD STE 124F
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:
34237-5354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-952-3999
Provider Business Mailing Address Fax Number:
941-217-4990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2831 RINGLING BLVD STE 124F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34237-5354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-952-3999
Provider Business Practice Location Address Fax Number:
941-217-4990
Provider Enumeration Date:
12/13/2019

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: 774581 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105003400 . 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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