=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275154221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STICKS ON THE GO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2020
-----------------------------------------------------
Last Update Date | 04/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4910 26TH ST E APT 202
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34203-4945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-300-2090
-----------------------------------------------------
Fax | 786-441-2360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 S WASHINGTON BLVD # 293
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34236-6943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | SHAKESHIA C PARRIMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-300-2090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------