1861646002 NPI number — ADVANCED FOOT & ANKLE OF CENTRAL FLORIDA

Table of content: JENNIFER BASS KINLAW PMHNP (NPI 1497634729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861646002 NPI number — ADVANCED FOOT & ANKLE OF CENTRAL FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FOOT & ANKLE OF CENTRAL FLORIDA
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:
1861646002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 KELTON AVE
Provider Second Line Business Mailing Address:
BLDG #3
Provider Business Mailing Address City Name:
OCOEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34761-3175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-521-7999
Provider Business Mailing Address Fax Number:
407-521-2227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 KELTON AVE
Provider Second Line Business Practice Location Address:
BLDG #3
Provider Business Practice Location Address City Name:
OCOEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34761-3175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-521-7999
Provider Business Practice Location Address Fax Number:
407-521-2227
Provider Enumeration Date:
11/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MAHAVIR
Authorized Official First Name:
NICK
Authorized Official Middle Name:
ASHOK
Authorized Official Title or Position:
OWNER/PODIATRIST
Authorized Official Telephone Number:
407-521-7999

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 011608300 . 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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