Healthcare Provider Details

I. General information

NPI: 1811175052
Provider Name (Legal Business Name): FT LAUDERDALE FIRST ASSIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SARNO ROAD SUITE 15
MELBOURNE FL
32935
US

IV. Provider business mailing address

214 CENTERVIEW DRIVE SUITE 100
BRENTWOOD TN
37027
US

V. Phone/Fax

Practice location:
  • Phone: 800-348-4565
  • Fax: 321-610-5115
Mailing address:
  • Phone: 615-345-5450
  • Fax: 615-345-5365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 3649
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberRN 3003202
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY T GRAY
Title or Position: CFO & TREASURER
Credential:
Phone: 615-345-5550