1023037272 NPI number — SPACE COAST SLEEP DISORDERS CENTER LLC

Table of content: (NPI 1023037272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023037272 NPI number — SPACE COAST SLEEP DISORDERS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST SLEEP DISORDERS CENTER LLC
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:
1023037272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 CLASSIC CT
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32940-8279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-255-9901
Provider Business Mailing Address Fax Number:
321-255-9902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 CLASSIC CT
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-8279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-255-9901
Provider Business Practice Location Address Fax Number:
321-255-9902
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STIGALL
Authorized Official First Name:
ANTONIO
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
321-255-9901

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X , with the licence number:  HCC7135 , 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: 1065447 . This is a "CARE PLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 36521 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7729847 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V3120 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: F301267 . This is a "FREEDOM HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 01092537 . This is a "AMERI GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 005021100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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