Provider Demographics
NPI:1376321083
Name:SCOFA LLC
Entity Type:Organization
Organization Name:SCOFA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DACELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ST MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-527-6888
Mailing Address - Street 1:6405 W GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-9354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6405 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-9354
Practice Address - Country:US
Practice Address - Phone:352-527-6888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies