1336467208 NPI number — WATERS MEDICAL CLINIC, LLC

Table of content: (NPI 1336467208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336467208 NPI number — WATERS MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERS MEDICAL CLINIC, 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:
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:
1336467208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 261825
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33685-1825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-885-9091
Provider Business Mailing Address Fax Number:
813-885-3527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4040 W WATERS AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33614-1958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-885-9091
Provider Business Practice Location Address Fax Number:
813-885-3527
Provider Enumeration Date:
05/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
THANHMY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OPERATING MANAGER
Authorized Official Telephone Number:
813-885-9091

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002995700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com