Provider Demographics
NPI:1174069967
Name:PATH MEDICAL, LLC
Entity type:Organization
Organization Name:PATH MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ANICIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:VICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:407-399-9070
Mailing Address - Street 1:PO BOX 638500
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8500
Mailing Address - Country:US
Mailing Address - Phone:407-367-5160
Mailing Address - Fax:407-730-9928
Practice Address - Street 1:6148 HANGING MOSS RD STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3792
Practice Address - Country:US
Practice Address - Phone:321-295-7977
Practice Address - Fax:321-295-7979
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATH MEDICAL CENTER HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8985261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL475580767OtherPIP