=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154203883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PROVIDER PARTNER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2025
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 S PENNSYLVANIA AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-5727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-208-9583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 S PENNSYLVANIA AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-5727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-208-9583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | TRACY OLSTEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 689-208-9583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------