Provider Demographics
NPI:1982152054
Name:VAXONSITE, LLC
Entity type:Organization
Organization Name:VAXONSITE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:CURTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-489-4358
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-1051
Mailing Address - Country:US
Mailing Address - Phone:727-489-4358
Mailing Address - Fax:813-342-7934
Practice Address - Street 1:1434 JAM LN
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3704
Practice Address - Country:US
Practice Address - Phone:727-489-4358
Practice Address - Fax:813-342-7934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC10745261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC10745OtherAHCA - HEALTH CARE CLINIC LICENSE # HCC10745