Provider Demographics
NPI:1124599824
Name:PRESTIGE OUTPATIENT PROVIDERS, LLC
Entity Type:Organization
Organization Name:PRESTIGE OUTPATIENT PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:OKSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTAMOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-517-1257
Mailing Address - Street 1:2338 IMMOKALEE RD # 141
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1445
Mailing Address - Country:US
Mailing Address - Phone:239-330-2933
Mailing Address - Fax:
Practice Address - Street 1:2338 IMMOKALEE RD # 186
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1445
Practice Address - Country:US
Practice Address - Phone:239-330-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-07
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty