=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942897582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VONOSTIR INNOVATION SERVICES, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2020
-----------------------------------------------------
Last Update Date | 10/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1406 KINGSLEY AVE UNIT A2
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-290-4601
-----------------------------------------------------
Fax | 904-290-4587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1406 KINGSLEY AVE UNIT A2
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-290-4601
-----------------------------------------------------
Fax | 904-290-4587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MR. KURT WILHELM OSTER
-----------------------------------------------------
Credential | MAT, MS, MSW, LCSW
-----------------------------------------------------
Telephone | 904-290-4601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------