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General NPI Number Information
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NPI Number | 1972251270
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Entity Type | Organization
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Legal Business Name | MD-PRAC LLC
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Dates
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Enumeration Date | 03/15/2022
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Last Update Date | 03/15/2022
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Provider Practice Location Address
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Address Line | 1860 SW FOUNTAINVIEW BLVD STE 100
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-4528
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Country | US
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Telephone | 833-245-5633
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Fax | 833-962-6213
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Provider Business Mailing Address
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Address Line | 4662 SW BRADBURY ST
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-5563
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Country | US
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Telephone | 833-245-5633
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Fax | 933-962-6213
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Authorized Official
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Title or Position | CONSULTANT
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Name | NAOMI MANNING
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Credential |
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Telephone | 833-245-5633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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