1871143453 NPI number — PROFESSIONAL SURGICAL ASSISTANTS

Table of content: (NPI 1871143453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871143453 NPI number — PROFESSIONAL SURGICAL ASSISTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL SURGICAL ASSISTANTS
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:
1871143453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 291613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32129-1613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-562-7052
Provider Business Mailing Address Fax Number:
800-821-4719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 ACKLINS CIR APT 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32119-9762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-269-0669
Provider Business Practice Location Address Fax Number:
800-821-4719
Provider Enumeration Date:
09/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
REPKA
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-269-0669

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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