Healthcare Provider Details

I. General information

NPI: 1871651620
Provider Name (Legal Business Name): NLS FAMILY ENTERPRISE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4372 SOUTHSIDE BLVD SUITE 303
JACKSONVILLE FL
32216-8501
US

IV. Provider business mailing address

4372 SOUTHSIDE BLVD SUITE 303
JACKSONVILLE FL
32216-8501
US

V. Phone/Fax

Practice location:
  • Phone: 904-646-4640
  • Fax: 904-646-4631
Mailing address:
  • Phone: 904-646-4640
  • Fax: 904-646-4631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPED 94
License Number StateFL

VIII. Authorized Official

Name: MR. NARENDRA SREERAM
Title or Position: PRESIDENT
Credential: CPED
Phone: 904-646-4640