1790087856 NPI number — BLUE LION MEDICAL

Table of content: (NPI 1790087856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790087856 NPI number — BLUE LION MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE LION MEDICAL
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:
1790087856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 814479
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33081-4479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-773-5744
Provider Business Mailing Address Fax Number:
954-962-1994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-8216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-773-5744
Provider Business Practice Location Address Fax Number:
954-962-1994
Provider Enumeration Date:
11/23/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HEINZ
Authorized Official First Name:
JEANA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
954-557-4140

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  PA9101635 , 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)