=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043948433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOMAL. V, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2022
-----------------------------------------------------
Last Update Date | 08/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6446 EVERGREEN PARK DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-617-2623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6446 EVERGREEN PARK DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-617-2623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KOMAL MEGHAT
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 662-617-2623
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------