1902439995 NPI number — ERIC GORMLEY LLC

Table of content: (NPI 1164614798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902439995 NPI number — ERIC GORMLEY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERIC GORMLEY 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:
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:
1902439995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
378 NE SURFSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34983-1244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-300-3257
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W CAPITOL AVE STE 1700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72201-3438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-999-3836
Provider Business Practice Location Address Fax Number:
501-361-1385
Provider Enumeration Date:
02/18/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GORMLEY
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AMBR
Authorized Official Telephone Number:
203-300-3257

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 105391300 . 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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