Provider Demographics
NPI:1346752755
Name:HAND & UPPER EXTREMITY SURGERY OF DAYTONA BEACH, LLC
Entity type:Organization
Organization Name:HAND & UPPER EXTREMITY SURGERY OF DAYTONA BEACH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NCPDP COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-9702
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-636-9702
Mailing Address - Fax:877-427-2307
Practice Address - Street 1:1241 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:479-636-9702
Practice Address - Fax:877-427-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9696332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site