1588856306 NPI number — MJS IRRV COMPLEX TRUST

Table of content: (NPI 1588856306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588856306 NPI number — MJS IRRV COMPLEX TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MJS IRRV COMPLEX TRUST
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:
FAIRMOUNT WALK-IN MED CLINIC
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:
1588856306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3750 US 27 N.
Provider Second Line Business Mailing Address:
SUITE 4-F
Provider Business Mailing Address City Name:
SEBRING
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33870-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-382-4949
Provider Business Mailing Address Fax Number:
863-382-3811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3750 US 27 N.
Provider Second Line Business Practice Location Address:
SUITE 4-F
Provider Business Practice Location Address City Name:
SEBRING
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33870-1690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-382-4949
Provider Business Practice Location Address Fax Number:
863-382-3811
Provider Enumeration Date:
08/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SERALDE
Authorized Official First Name:
CIRILO
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/TRUSTEE
Authorized Official Telephone Number:
863-382-4949

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  ME0043253 , 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: 21429 . This is a "VICTOR M SERALDE MCR UPIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 41214C . This is a "MEDICARE PROVIDER CIRILO SERALDE FOR FAIRMOUNT CLINIC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K2401 . This is a "MEDICARE PART B GROUP PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 28115A . This is a "VICTOR SERALDE PROVIDER NUMBER FOR FAIRMOUNT CLINIC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10D0293128 . This is a "CLIA GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54734 . This is a "CIRILO M SERALDE MCR UPIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 259715200 . This is a "MEDIPASS PROVIDER NUMBER GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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