=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346712098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAID MADE SIMPLE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2018
-----------------------------------------------------
Last Update Date | 12/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27847 SE HWY 19
-----------------------------------------------------
City | OLD TOWN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32680-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-231-1481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27847 SE HWY 19
-----------------------------------------------------
City | OLD TOWN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32680-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-231-1481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PATRICK E ALLEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 352-231-1481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------