1568892800 NPI number — PREVENTATIVE MEDICINE GROUP, LLC

Table of content: (NPI 1568892800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568892800 NPI number — PREVENTATIVE MEDICINE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVENTATIVE MEDICINE GROUP, 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:
1568892800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 TIVOLI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34104-0863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-877-2951
Provider Business Mailing Address Fax Number:
239-349-2608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28901 TRAILS EDGE BLVD
Provider Second Line Business Practice Location Address:
UNIT 103
Provider Business Practice Location Address City Name:
BONITA SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34134-7588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-877-2951
Provider Business Practice Location Address Fax Number:
239-349-2608
Provider Enumeration Date:
11/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WOODRING
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
FREDERICK
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
239-877-2951

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X , with the licence number:  OS 10008 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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