=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124731047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERNA LDP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2023
-----------------------------------------------------
Last Update Date | 01/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4848 NW 24TH CT UNIT 428
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-444-2779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3901 W BROWARD BLVD UNIT 120504
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-8422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-444-2779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. ERNA JULIEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-444-2779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------