Provider Demographics
NPI:1336680255
Name:MOHAMMED, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:MOHAMMED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11794 CASA LAGO LN APT 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1645
Mailing Address - Country:US
Mailing Address - Phone:813-453-2769
Mailing Address - Fax:
Practice Address - Street 1:7509 CANAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-5605
Practice Address - Country:US
Practice Address - Phone:813-453-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility