=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720894199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZODU THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 W SR 434 STE 1000
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-4969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-304-9638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 W SR 434 STE 1000
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-4969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-304-9638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMUEL E DUANY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-986-6595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------