1316186893 NPI number — FLAGLER DIAGNOSTIC AND SLEEPING DISORDER, INC.

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 1316186893 NPI number — FLAGLER DIAGNOSTIC AND SLEEPING DISORDER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLAGLER DIAGNOSTIC AND SLEEPING DISORDER, 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:
1316186893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4721 E. MOODY BLVD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
BUNNELL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-586-6229
Provider Business Mailing Address Fax Number:
386-263-2975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 W. CYPRESS CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FT. LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-306-3760
Provider Business Practice Location Address Fax Number:
877-537-8123
Provider Enumeration Date:
02/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROCHES
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
FACILITY DIRECTOR OFFICE MANAGER
Authorized Official Telephone Number:
386-586-6229

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X , with the licence number:  HCC8433 , 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: V0073 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V0073 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 018211800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115404700 . 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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