1073006631 NPI number — LIVING FLORIDA HEALTHCARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073006631 NPI number — LIVING FLORIDA HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING FLORIDA HEALTHCARE 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:
1073006631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4804 EDGEWATER DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32804-1126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-574-2121
Provider Business Mailing Address Fax Number:
866-682-4175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4804 EDGEWATER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32804-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-330-9330
Provider Business Practice Location Address Fax Number:
321-697-7000
Provider Enumeration Date:
06/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
TOM
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
407-574-2121

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114631700 . 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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