1811136773 NPI number — INDIAN RIVER INTERNAL MEDICINE, 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 1811136773 NPI number — INDIAN RIVER INTERNAL MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN RIVER INTERNAL MEDICINE, 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:
1811136773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7935 BAY ST
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
SEBASTIAN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32958-3282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-581-1881
Provider Business Mailing Address Fax Number:
772-581-1885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7935 BAY ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SEBASTIAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32958-3282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-581-1881
Provider Business Practice Location Address Fax Number:
772-581-1885
Provider Enumeration Date:
02/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PRIETO
Authorized Official First Name:
ENIO
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
SOLE MANAGING MEMBER
Authorized Official Telephone Number:
772-581-1881

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME80380 , 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)





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