Provider Demographics
NPI:1043520091
Name:AHP OF SOUTH BROWARD LLC
Entity type:Organization
Organization Name:AHP OF SOUTH BROWARD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CREDENTIALING & ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BLASETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-945-5330
Mailing Address - Street 1:3079 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2215
Mailing Address - Country:US
Mailing Address - Phone:770-945-5330
Mailing Address - Fax:678-546-3606
Practice Address - Street 1:11011 SHERIDAN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1505
Practice Address - Country:US
Practice Address - Phone:645-435-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty