Basic Information
| Provider Information | |||||||||
| NPI: | 1891450144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STORK SQUAD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 LITHIA PINECREST RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136858404 | ||||||||
| FaxNumber: | 8132980620 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 LITHIA PINECREST RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136858404 | ||||||||
| FaxNumber: | 8132980620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2021 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | VERBARG | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8136858404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LM | ||||||||
| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Midwife |
No ID Information.