1124304167 NPI number — SOUTHSIDE COUNSELLING CENTER 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 1124304167 NPI number — SOUTHSIDE COUNSELLING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE COUNSELLING 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:
1124304167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2950 HALCYON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-6689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-316-3365
Provider Business Mailing Address Fax Number:
904-292-2409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3681 CAROL ANN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32223-7394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-316-3365
Provider Business Practice Location Address Fax Number:
904-292-2409
Provider Enumeration Date:
10/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
CARMELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-316-3365

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  MH8370 , 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)





Copyright © 2007-2026 www.npivalidator.com