1902095870 NPI number — CAMEL IRRV COMPLEX TRUST

Table of content: (NPI 1902095870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902095870 NPI number — CAMEL IRRV COMPLEX TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMEL IRRV COMPLEX TRUST
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:
1902095870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3750 US 27 N STE 4F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBRING
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33870-1658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-382-8080
Provider Business Mailing Address Fax Number:
863-382-3811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3750 US 27 N STE 4F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBRING
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33870-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-382-8080
Provider Business Practice Location Address Fax Number:
863-382-3811
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SERALDE
Authorized Official First Name:
CIRILO
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
863-382-8080

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D21429 . This is a "VICTOR M. SERALDE MD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: D54734 . This is a "CIRILO M. SERALDE, JR. MD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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