Provider Demographics
NPI:1235433749
Name:66101 SUNSET STRIP,LLC
Entity Type:Organization
Organization Name:66101 SUNSET STRIP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDNOLIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-575-2833
Mailing Address - Street 1:40 SE 5TH ST STE 406
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-6003
Mailing Address - Country:US
Mailing Address - Phone:561-368-7118
Mailing Address - Fax:561-368-7116
Practice Address - Street 1:40 SOUTH EAST 5TH STREET, SUITE 406
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432
Practice Address - Country:US
Practice Address - Phone:561-368-7118
Practice Address - Fax:561-368-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22512261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical