Provider Demographics
NPI:1396326807
Name:COTG 2021
Entity type:Organization
Organization Name:COTG 2021
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-327-7481
Mailing Address - Street 1:1220 PROSPECT AVE STE 294
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-7300
Mailing Address - Country:US
Mailing Address - Phone:772-300-6531
Mailing Address - Fax:
Practice Address - Street 1:1385 CYPRESS AVE UNIT 104
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5919
Practice Address - Country:US
Practice Address - Phone:321-327-7481
Practice Address - Fax:888-453-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-16
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNAOtherNA