MEDICARE: MOBILE VISITING PRACTITIONERS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1265915359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE VISITING PRACTITIONERS, LLC

Provider Business Mailing Address
First Line	:	140 S BEACH ST STE 202
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-4409
Country	:	US
Telephone Number	:	888-506-8836
Fax Number	:	888-506-8837

Provider Business Practice Location Address
First Line	:	140 S BEACH ST STE 202
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-4409
Country	:	US
Telephone Number	:	888-506-8836
Fax Number	:	888-506-8837

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	EDWARD R KOP
Credential	:
Telephone Number	:	352-362-0627

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	11/05/2020

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