1811042286 NPI number — PALMS OF LAUDERDALE LAKES THE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811042286 NPI number — PALMS OF LAUDERDALE LAKES THE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMS OF LAUDERDALE LAKES THE 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:
6
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:
1811042286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 NE MIAMI GARDENS DR
Provider Second Line Business Mailing Address:
#368
Provider Business Mailing Address City Name:
NORTH MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33179-5035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3370 NW 47TH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUDERDALE LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33319-6701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-733-0655
Provider Business Practice Location Address Fax Number:
954-733-1521
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOGOMILSKY
Authorized Official First Name:
TZVI
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED MEMBER
Authorized Official Telephone Number:
305-401-7901

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1098096 , 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: 032153200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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