Provider Demographics
NPI:1750722278
Name:MALLORY VENTSAM ENTERPRISES, LLC
Entity type:Organization
Organization Name:MALLORY VENTSAM ENTERPRISES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:VENTSAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-797-6500
Mailing Address - Street 1:12627 PORTMARNOCK DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-5416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-6939
Practice Address - Country:US
Practice Address - Phone:727-498-8544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment