1962908384 NPI number — MISS RAQUEL MEDINA VALENTIN SLPA,ITDS

Table of content: MISS RAQUEL MEDINA VALENTIN SLPA,ITDS (NPI 1962908384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962908384 NPI number — MISS RAQUEL MEDINA VALENTIN SLPA,ITDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA VALENTIN
Provider First Name:
RAQUEL
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
SLPA,ITDS
Provider Gender Code:
F

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:
1962908384
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1737 ORANGE VIEW WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34769-5403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-508-1310
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4119 NEPTUNE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34769-6741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-913-1010
Provider Business Practice Location Address Fax Number:
407-992-8697
Provider Enumeration Date:
04/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2355S0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 024660100 . 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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