1639309842 NPI number — BOND COMMUNITY HEALTH CENTER

Table of content: (NPI 1639309842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639309842 NPI number — BOND COMMUNITY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOND COMMUNITY HEALTH CENTER
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:
KAY FREEMAN HEALTH 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:
1639309842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 SOUTH GADSDEN ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-576-4073
Provider Business Mailing Address Fax Number:
850-577-0675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2729-8 MUNICIPAL WAY
Provider Second Line Business Practice Location Address:
KAY FREEMAN HEALTH CENTER
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-576-4073
Provider Business Practice Location Address Fax Number:
850-576-0151
Provider Enumeration Date:
07/22/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAYSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
850-576-4073

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME76689 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: ME80809 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: ME101353 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: OS8157 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: ARNP3353752 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0809X , with the licence number: ARNP1727122 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 060551401 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060551400 . This is a "MEDICAID FFS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101909 . This is a "MEDICARE FQHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 060551402 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".