1578865028 NPI number — PEAK PROVIDER SERVICES, 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 1578865028 NPI number — PEAK PROVIDER SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK PROVIDER 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:
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:
1578865028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLIDAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34692-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-505-0459
Provider Business Mailing Address Fax Number:
727-857-3381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2435 US HIGHWAY 19
Provider Second Line Business Practice Location Address:
SUITE 540
Provider Business Practice Location Address City Name:
HOLIDAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34691-3903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-505-0459
Provider Business Practice Location Address Fax Number:
727-940-3492
Provider Enumeration Date:
12/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KOCINA
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
727-505-0459

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 686781201 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 686781296 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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