=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578830170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRHOMEVISITCOMLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2011
-----------------------------------------------------
Last Update Date | 05/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 745 ORIENTA AVE STE 1191
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-5619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-782-3702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 150038
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32715-0038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN NIMBARGI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-782-3702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME85807
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------