Provider Demographics
NPI:1487891859
Name:LYMPHEDEMA CARE CENTER OF NORTH FLORIDA, INC.
Entity type:Organization
Organization Name:LYMPHEDEMA CARE CENTER OF NORTH FLORIDA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIANELA
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CSIT, CLT
Authorized Official - Phone:904-375-0830
Mailing Address - Street 1:8563 ARGYLE BUSINESS LOOP
Mailing Address - Street 2:SUITE #2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-6668
Mailing Address - Country:US
Mailing Address - Phone:904-375-0830
Mailing Address - Fax:877-811-4031
Practice Address - Street 1:8563 ARGYLE BUSINESS LOOP
Practice Address - Street 2:SUITE #2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-6668
Practice Address - Country:US
Practice Address - Phone:904-375-0830
Practice Address - Fax:877-811-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11418305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCD935AOtherMEDICARE PTAN
FL003444400Medicaid
FL8899886-00FLMedicaid