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General NPI Number Information
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NPI Number | 1881025005
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Entity Type | Organization
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Legal Business Name | ELM TREE LODGE
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Dates
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Enumeration Date | 12/13/2013
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Last Update Date | 12/13/2013
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Provider Practice Location Address
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Address Line | 6205 VIOLA LANE
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City | NEW PORT RICHEY
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State | FL
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Zip | 34653
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Country | US
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Telephone | 727-845-0609
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Fax |
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Provider Business Mailing Address
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Address Line | 6205 VIOLA LN
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City | NEW PORT RICHEY
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State | FL
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Zip | 34653-1701
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Country | US
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Telephone | 727-845-0609
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARGE COFFEY
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Credential |
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Telephone | 727-845-0609
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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 | AL8589
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License Number State | FL
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