Provider Demographics
NPI:1396062451
Name:LYMPHEDEMA CARE CENTER OF NORTH FLORIDA, INC.
Entity type:Organization
Organization Name:LYMPHEDEMA CARE CENTER OF NORTH FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CLT, CKTP
Authorized Official - Phone:904-375-0830
Mailing Address - Street 1:8563 ARGYLE BUSINESS LOOP
Mailing Address - Street 2:SUITE #2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-6668
Mailing Address - Country:US
Mailing Address - Phone:904-375-0830
Mailing Address - Fax:877-811-4031
Practice Address - Street 1:8563 ARGYLE BUSINESS LOOP
Practice Address - Street 2:SUITE #2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-6668
Practice Address - Country:US
Practice Address - Phone:904-375-0830
Practice Address - Fax:877-811-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11418332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ173GOtherBLUE CROSS BLUE SHIELD FL
FL9959348OtherAETNA
FL=========OtherTRICARE SOUTH
FL1487891859Medicare PIN