Provider Demographics
NPI:1386005759
Name:COMPREHENSIVE EAR NOSE THROAT ALLERGY SINUS LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE EAR NOSE THROAT ALLERGY SINUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LINDSTROM
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:321-802-6697
Mailing Address - Street 1:1314 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3117
Mailing Address - Country:US
Mailing Address - Phone:321-802-6697
Mailing Address - Fax:321-802-3158
Practice Address - Street 1:1314 PINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3117
Practice Address - Country:US
Practice Address - Phone:321-802-6697
Practice Address - Fax:321-802-3158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111877207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004547400Medicaid
FLFV242OtherMEDICARE PTAN