Basic Information
| Provider Information | |||||||||
| NPI: | 1215321617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NST FAMILY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 600 SOUTH PINE ISLAND ROAD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544744401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 S PINE ISLAND RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544744401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | WASHINGTON | ||||||||
| AuthorizedOfficialFirstName: | JELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9544744401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.