Basic Information
Provider Information | |||||||||
NPI: | 1275665697 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NANCE | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2654 ISLAND DR | ||||||||
Address2: |   | ||||||||
City: | MIRAMAR | ||||||||
State: | FL | ||||||||
PostalCode: | 330234604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549866871 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4720 N. STATE RD.7 | ||||||||
Address2: | BLDG B | ||||||||
City: | FT. LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 33319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544973856 | ||||||||
FaxNumber: | 9544973857 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.