Provider Demographics
NPI:1922612233
Name:MEDISUPPORT LLC
Entity Type:Organization
Organization Name:MEDISUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-444-2879
Mailing Address - Street 1:15151 S US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-4482
Mailing Address - Country:US
Mailing Address - Phone:954-444-2879
Mailing Address - Fax:
Practice Address - Street 1:15151 S US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-4482
Practice Address - Country:US
Practice Address - Phone:954-444-2879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty