Basic Information
Provider Information | |||||||||
NPI: | 1558970004 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREENBERG | ||||||||
FirstName: | ELICE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 803 RIDGEFIELD AVE | ||||||||
Address2: |   | ||||||||
City: | OCOEE | ||||||||
State: | FL | ||||||||
PostalCode: | 347612527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078648389 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1160 S SEMORAN BLVD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328071461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006765130 | ||||||||
FaxNumber: | 8889595753 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2020 | ||||||||
LastUpdateDate: | 11/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | N |   |   |   |   | 106E00000X | 0-21-12887 | FL | Y |   |   |   |   |
No ID Information.