=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144627894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUDNER HENRI SR. CNA212386
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2014
-----------------------------------------------------
Last Update Date | 11/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 841 SW DURHAM TERR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-289-3730
-----------------------------------------------------
Fax | 772-618-6561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 841 SW DURHAM TER
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-1547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-289-3730
-----------------------------------------------------
Fax | 772-618-6561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | CNA212386
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------