1003279613 NPI number — LEE COUNTY YOUTH DEVELOPMENT CENTER

Table of content: (NPI 1003279613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003279613 NPI number — LEE COUNTY YOUTH DEVELOPMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEE COUNTY YOUTH DEVELOPMENT 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:
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:
1003279613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1109 SPRING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OPELIKA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36801-5345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-749-2996
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 SPRING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OPELIKA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36801-5345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-749-2996
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
334-749-2996

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  671 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1861631962 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: RTF0001H , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1336396399 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1407003486 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1558475319 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1427295591 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 339100001 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1619368875 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 339090245 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529804070 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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