|
NPI
|
1396755757
|
|
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
|
|
NPI Deactivation Date
|
06/25/2026
|
|
The date that the provider's NPI was deactivated in the NPS.
|
|
Other Provider Identifier 1
|
101622200
|
|
Other Provider Identifier #1
|
|
Other Provider Identifier Type 1
|
MEDICAID
|
|
Other Provider Identifier Type #1
|
|
Other Provider Identifier State 1
|
FL
|
|
Other Provider Identifier State #1
|
|
Other Provider Identifier Issuer 1
|
Florida Medicaid Provider ID
|
|
Other Provider Identifier Issuer #1
|