Provider Demographics
NPI:1972071801
Name:C12 MEDICAL LLC
Entity Type:Organization
Organization Name:C12 MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-251-7782
Mailing Address - Street 1:8498 108TH WAY
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4318
Mailing Address - Country:US
Mailing Address - Phone:727-251-7782
Mailing Address - Fax:
Practice Address - Street 1:333 16TH AVE SE
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-4407
Practice Address - Country:US
Practice Address - Phone:727-251-7782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT10920OtherSTATE LICENSE