1164783494 NPI number — AGAPELIFE HEALTH GROUP, LLC

Table of content: (NPI 1164783494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164783494 NPI number — AGAPELIFE HEALTH GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPELIFE HEALTH GROUP, 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:
BRIGHTSTAR CARE OF THE BEACHES & PONTE VEDRA
Provider Other Organization Name Type Code:
3
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:
1164783494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 SAINT JOHNS BLUFF RD S
Provider Second Line Business Mailing Address:
1-214
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224-2682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-807-9955
Provider Business Mailing Address Fax Number:
904-807-9954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12187 BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32246-0676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-807-9955
Provider Business Practice Location Address Fax Number:
904-807-9954
Provider Enumeration Date:
06/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HART
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OWNER, AGENCY DIRECTOR
Authorized Official Telephone Number:
904-807-9955

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1514 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 299994085 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X , with the licence number: 299994085 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1514 . This is a "HEALTH CARE SERVICES POOL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 299994085 . This is a "ACHA HOME HEALTH AGENCY LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 232597 . This is a "ACHA HOMEMAKER COMPANION LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10D2043310 . This is a "CLIA WAIVER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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