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NPI
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1730120122
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10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
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NPI Deactivation Date
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01/23/2025
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The date that the provider's NPI was deactivated in the NPS.
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Other Provider Identifier 1
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104677500
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Other Provider Identifier #1
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Other Provider Identifier Type 1
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MEDICAID
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Other Provider Identifier Type #1
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Other Provider Identifier State 1
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FL
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Other Provider Identifier State #1
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Other Provider Identifier Issuer 1
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Florida Medicaid Provider ID
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Other Provider Identifier Issuer #1
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