Provider Demographics
NPI:1376955633
Name:MULDER, COLLIN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:MULDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14108 OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-1362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14108 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1362
Practice Address - Country:US
Practice Address - Phone:616-240-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9047310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003855600Medicaid