=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174299333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIOFOURMIS CARE FL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2021
-----------------------------------------------------
Last Update Date | 11/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1857 WELLS RD STE 209B
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-626-1049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 SE 2ND AVE STE 2000
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33131-2185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-626-1049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, PAYER CONTRACTING
-----------------------------------------------------
Name | DEVION SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 424-326-8711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------