MEDICARE: NLS FAMILY ENTERPRISE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	PED 94	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M2790	OTHER	FL	BLUE CROSS BLUESHIELD

General Provider Information

NPI Number	:	1871651620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NLS FAMILY ENTERPRISE, INC.

Provider Business Mailing Address
First Line	:	4372 SOUTHSIDE BLVD
Second Line	:	SUITE 303
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8501
Country	:	US
Telephone Number	:	904-646-4640
Fax Number	:	904-646-4631

Provider Business Practice Location Address
First Line	:	4372 SOUTHSIDE BLVD
Second Line	:	SUITE 303
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8501
Country	:	US
Telephone Number	:	904-646-4640
Fax Number	:	904-646-4631

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. NARENDRA SREERAM
Credential	:	CPED
Telephone Number	:	904-646-4640

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	04/20/2008

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Directions to “NLS FAMILY ENTERPRISE, INC. ” Practice Location

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