Provider Demographics
NPI:1821863770
Name:VERNU 2
Entity Type:Organization
Organization Name:VERNU 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-2036
Mailing Address - Street 1:6775 CROSSWINDS DR N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5471
Mailing Address - Country:US
Mailing Address - Phone:678-580-3823
Mailing Address - Fax:
Practice Address - Street 1:6775 CROSSWINDS DR N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5471
Practice Address - Country:US
Practice Address - Phone:678-580-3823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VERNU 2
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty