1245678184 NPI number — BRIDGE OF HOPE CENTRAL FLORIDA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245678184 NPI number — BRIDGE OF HOPE CENTRAL FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE OF HOPE CENTRAL FLORIDA
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:
BRIDGE OF HOPE CENTRAL FLORIDA
Provider Other Organization Name Type Code:
4
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:
1245678184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 452878
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34745-2878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-575-4636
Provider Business Mailing Address Fax Number:
321-250-7425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 KEVSTIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34744-5844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-575-4536
Provider Business Practice Location Address Fax Number:
321-250-7425
Provider Enumeration Date:
06/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OPERATION MANAGER
Authorized Official Telephone Number:
407-575-4636

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 21145 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT 1181 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SA10475 , 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: 000867500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000867502 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000867501 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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