1851776868 NPI number — METCARE OF DELAND

Table of content: (NPI 1851776868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851776868 NPI number — METCARE OF DELAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METCARE OF DELAND
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:
1851776868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 BLUE LAGOON DR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-500-2114
Provider Business Mailing Address Fax Number:
305-370-6024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
929 N SPRING GARDEN AVE
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32720-0900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-805-8530
Provider Business Practice Location Address Fax Number:
502-508-4773
Provider Enumeration Date:
07/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ROSELLO
Authorized Official First Name:
GEMMA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
305-500-2000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CX415B . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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