=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598362410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE I.V. MEDICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2020
-----------------------------------------------------
Last Update Date | 10/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N ORANGE AVE STE 800
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32801-2381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-448-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10196 STOREY GROVE WAY
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-0086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-291-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | KYLE ROBERT HAINES
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 601-448-9675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------