Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH0002540 | FL |
NPI | 1265530448 |
---|---|
Provider Name | Dr. William V Longstreth |
First Address | Deerfield Beach, FL 33441-5632 |
Second Address | Deerfield Beach, FL 33441-5632 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CH00002540 | STATE LISCENSE (01) | FL |
T88900 | (02) | FL |