1487642427 NPI number — TIERRA PINES CENTER, LLC

Table of content: (NPI 1487642427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487642427 NPI number — TIERRA PINES CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIERRA PINES CENTER, 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:
TIERRA PINES CENTER
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:
1487642427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7380 ULMERTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33771-4512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-535-9833
Provider Business Mailing Address Fax Number:
727-536-4525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7380 ULMERTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33771-4512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-535-9833
Provider Business Practice Location Address Fax Number:
727-536-4525
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ZIOLKOWSKI
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
ALISE
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
813-558-6629

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF15580961 , 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: C105398 . This is a "UNITED AMERICAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 026056800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71-01209 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 71-05236 . This is a "EVERCARE HH CONNECTION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K85 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 026056800 . 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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