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General NPI Number Information
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NPI Number | 1639861966
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Entity Type | Organization
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Legal Business Name | THE IRON VILLAGE
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Dates
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Enumeration Date | 05/24/2023
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Last Update Date | 05/24/2023
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Provider Practice Location Address
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Address Line | 4059 THOMAS ST STE A02
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City | OXFORD
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State | FL
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Zip | 34484-3452
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Country | US
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Telephone | 712-541-1447
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Fax |
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Provider Business Mailing Address
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Address Line | 4059 THOMAS ST STE A02
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City | OXFORD
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State | FL
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Zip | 34484-3452
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Country | US
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Telephone | 712-541-1447
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LUKE ELDER
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Credential |
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Telephone | 712-541-1447
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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