Provider Demographics
NPI:1952844326
Name:STUMP MED
Entity Type:Organization
Organization Name:STUMP MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRETHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-502-8213
Mailing Address - Street 1:2876 LANTANA LAKES DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-1807
Mailing Address - Country:US
Mailing Address - Phone:904-502-8213
Mailing Address - Fax:
Practice Address - Street 1:2876 LANTANA LAKES DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-1807
Practice Address - Country:US
Practice Address - Phone:904-502-8213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid