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General NPI Number Information
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NPI Number | 1104370220
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Entity Type | Organization
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Legal Business Name | PREMIER DYSPHAGIA MANAGEMENT, INC
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Dates
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Enumeration Date | 08/05/2016
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Last Update Date | 08/05/2016
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Provider Practice Location Address
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Address Line | 218 RINGWOOD DR
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City | WINTER SPRINGS
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State | FL
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Zip | 32708-4945
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Country | US
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Telephone | 407-695-8585
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Fax | 407-695-8585
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Provider Business Mailing Address
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Address Line | 218 RINGWOOD DR
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City | WINTER SPRINGS
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State | FL
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Zip | 32708-4945
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Country | US
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Telephone | 407-695-8585
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Fax | 407-695-8585
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Authorized Official
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Title or Position | S,T
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Name | MRS. KELLY TEASE
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Credential |
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Telephone | 407-695-8585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA2695
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA4443
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License Number State | FL
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