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General NPI Number Information
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NPI Number | 1730687070
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Entity Type | Organization
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Legal Business Name | LICE AVENGERS OF SW FLORIDA LLC
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Dates
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Enumeration Date | 01/31/2018
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Last Update Date | 01/31/2018
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Provider Practice Location Address
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Address Line | 8881 TERRENE CT STE 104
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-9528
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Country | US
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Telephone | 239-237-0757
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Fax |
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Provider Business Mailing Address
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Address Line | 8881 TERRENE CT STE 104
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-9528
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Country | US
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Telephone | 239-237-0757
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JEFFREY RANDOLPH
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Credential |
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Telephone | 608-509-6807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number |
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License Number State |
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