1821097767 NPI number — PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC

Table of content: (NPI 1821097767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821097767 NPI number — PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT 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:
PEACE RIVER 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:
1821097767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTOW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33831-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-519-0575
Provider Business Mailing Address Fax Number:
863-582-9251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1239 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARTOW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33830-5058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-519-0575
Provider Business Practice Location Address Fax Number:
863-582-9251
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DECK
Authorized Official First Name:
JO
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
863-519-0575

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 284300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 060310405 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310406 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310417 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310424 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 761545101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310401 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310410 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310425 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310437 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310409 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310414 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310416 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310421 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310422 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310423 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310404 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310418 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310428 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310432 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060310434 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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