=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528772860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IKNA KRYSIAK DO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 NW 49TH AVE STE 303
-----------------------------------------------------
City | LAUDERDALE LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-7263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-714-0684
-----------------------------------------------------
Fax | 954-714-4993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 NW 49TH AVE STE 303
-----------------------------------------------------
City | LAUDERDALE LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-7263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-714-0684
-----------------------------------------------------
Fax | 954-714-4993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IKNA KRYSIAK
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 312-860-8447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------