Basic Information
| Provider Information | |||||||||
| NPI: | 1538679576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 S.W. ARCHER ROAD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 S.W. ARCHER ROAD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2017 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OBRIEN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | RICHARD | ||||||||
| AuthorizedOfficialTitleorPosition: | LPN | ||||||||
| AuthorizedOfficialTelephone: | 3523761611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LPN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN5148178 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.