1790189264 NPI number — MICHELLE MARIE HUDIMAC M.ED.

Table of content: MICHELLE MARIE HUDIMAC M.ED. (NPI 1790189264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790189264 NPI number — MICHELLE MARIE HUDIMAC M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDIMAC
Provider First Name:
MICHELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED.
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:
1790189264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3785 MAPLE GROVE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32129-8618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-288-9648
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 THORNBERRY BRANCH LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32124-3652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-872-4892
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2014

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104801300 . 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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