1790408052 NPI number — THE MICHELES LLC

Table of content: (NPI 1790408052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790408052 NPI number — THE MICHELES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MICHELES LLC
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:
1790408052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 471118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33247-1118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-878-4826
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34870 SW 212TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33034-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-878-4826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BYRD
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
305-878-4826

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116686100 . 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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