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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  N    
106E00000X0-21-12887FLY    

No ID Information.


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