1073788691 NPI number — WEST ORANGE SPEECH PATHOLOGIST, INC.

Table of content: (NPI 1073788691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073788691 NPI number — WEST ORANGE SPEECH PATHOLOGIST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST ORANGE SPEECH PATHOLOGIST, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073788691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 555907
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32855-5907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-298-5300
Provider Business Mailing Address Fax Number:
407-296-0026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6388 SILVER STAR RD STE 2E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32818-3235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-298-5300
Provider Business Practice Location Address Fax Number:
407-296-0026
Provider Enumeration Date:
04/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TATUM-RILEY
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/SLP
Authorized Official Telephone Number:
407-298-5300

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SA1245 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202579 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 882834200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18348 . This is a "STAYWELL / WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 880650196 . This is a "MEDWAIVER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 882834200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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