| Back Nine Ventures Corp | |
|
6236 Scarlet Darter Way Tampa FL 33625-3209 | |
| (813) 261-3171 | |
| Not Available |
| Full Name | Back Nine Ventures Corp |
|---|---|
| Speciality | Counselor |
| Location | 6236 Scarlet Darter Way, Tampa, Florida |
| Authorized Official Name and Position | Chad Hardwick (AUTHORIZED OFFICIAL) |
| Authorized Official Contact | 8132613171 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Back Nine Ventures Corp 6236 Scarlet Darter Way Tampa FL 33625-3209 Ph: (813) 261-3171 | Back Nine Ventures Corp 6236 Scarlet Darter Way Tampa FL 33625-3209 Ph: (813) 261-3171 |
| NPI Number | 1386482149 |
|---|---|
| Provider Enumeration Date | 07/17/2024 |
| Last Update Date | 07/17/2024 |
| Certification Date | 07/16/2024 |
| Medicare PECOS PAC ID | 8921530957 |
|---|---|
| Medicare Enrollment ID | O20241016000913 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1386482149 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Lorianna M Kardok |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1508300328 PECOS PAC ID: 7719419746 Enrollment ID: I20241016001049 |
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