1194012252 NPI number — CHILDRENS HOME SOCIETY TREASURE COAST

Table of content: (NPI 1194012252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194012252 NPI number — CHILDRENS HOME SOCIETY TREASURE COAST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS HOME SOCIETY TREASURE COAST
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:
1194012252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1485 S SEMORAN BLVD
Provider Second Line Business Mailing Address:
SUITE 1448
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32792-5533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-397-3000
Provider Business Mailing Address Fax Number:
321-397-3016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 NW PEACOCK BLVD
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-344-4020
Provider Business Practice Location Address Fax Number:
772-344-4038
Provider Enumeration Date:
07/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BUNDY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-397-3000

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com