1790793016 NPI number — LIFETIME MEDICAL CARE PA

Table of content: (NPI 1790793016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790793016 NPI number — LIFETIME MEDICAL CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME MEDICAL CARE PA
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:
1790793016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 US HIGHWAY 17
Provider Second Line Business Mailing Address:
SUITE 18-302
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-8231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-278-0016
Provider Business Mailing Address Fax Number:
904-278-4217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-5571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-278-0016
Provider Business Practice Location Address Fax Number:
904-278-4217
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EL RIMAWI
Authorized Official First Name:
NIDAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-278-0016

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  ME81222 , 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)

  • Identifier: 7388361 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 01528 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6965204 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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