1104925429 NPI number — HEARTLAND REHABILITATION SERVICES OF FLORIDA LLC

Table of content: (NPI 1104925429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104925429 NPI number — HEARTLAND REHABILITATION SERVICES OF FLORIDA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND REHABILITATION SERVICES OF FLORIDA LLC
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:
HEARTLAND REHABILITATION SERVICES
Provider Other Organization Name Type Code:
3
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:
1104925429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 KINGSLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-4847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-264-2156
Provider Business Mailing Address Fax Number:
904-264-8350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15260 NW 147TH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALACHUA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32615-5309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-462-4349
Provider Business Practice Location Address Fax Number:
386-418-0824
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAZARUS
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VICE PRESIDENT - REIMBURSEMENTS
Authorized Official Telephone Number:
419-252-5541

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 028496300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1617682 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8845212-35 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q1C . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 160630535 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4477946 . This is a "AETNA NON-HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 102701 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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