1164485074 NPI number — TRI COUNTY HUMAN SERVICES, INC.

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 1164485074 NPI number — TRI COUNTY HUMAN SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI COUNTY HUMAN SERVICES, 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:
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:
1164485074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 CRYSTAL LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33801-5979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-709-9392
Provider Business Mailing Address Fax Number:
863-709-8923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2725 HWY 60 E
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:
33830-8872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-533-5860
Provider Business Practice Location Address Fax Number:
863-533-5272
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GELDART
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
BLAIR
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
863-533-4139

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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