=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245870112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISITING PHYSICIANS OF SOUTH FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2020
-----------------------------------------------------
Last Update Date | 01/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 10TH ST E STE B
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-4161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-777-0101
-----------------------------------------------------
Fax | 989-777-5803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 MEADOWBROOK ST
-----------------------------------------------------
City | LAKE PLACID
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33852-5727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-941-9975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MBR
-----------------------------------------------------
Name | TONI-LYNN WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-777-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------