Provider Demographics
NPI:1811175052
Name:FT LAUDERDALE FIRST ASSIST, LLC
Entity type:Organization
Organization Name:FT LAUDERDALE FIRST ASSIST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO & TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-345-5550
Mailing Address - Street 1:214 CENTERVIEW DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-345-5450
Mailing Address - Fax:615-345-5365
Practice Address - Street 1:1600 SARNO ROAD
Practice Address - Street 2:SUITE 15
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:800-348-4565
Practice Address - Fax:321-610-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3649363AS0400X
FLRN 3003202364SM0705X
363AS0400X, 364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-SurgicalGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001019600Medicaid