1265690366 NPI number — STALLWORTH COMMUNITY SERVICES INC

Table of content: (NPI 1265690366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265690366 NPI number — STALLWORTH COMMUNITY SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STALLWORTH COMMUNITY SERVICES 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:
SUCCESSFUL DEVELOPMENT INC
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:
1265690366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 57
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLEVAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-536-4449
Provider Business Mailing Address Fax Number:
941-355-8699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 26TH AVENUE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-536-4449
Provider Business Practice Location Address Fax Number:
941-355-8699
Provider Enumeration Date:
05/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STALLWORTH
Authorized Official First Name:
JANELL
Authorized Official Middle Name:
LATRICE
Authorized Official Title or Position:
PRESIDENT EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
941-536-4449

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 690209096 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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