1194356386 NPI number — MR. ED'S CIRCLE OF TRUST, INC.

Table of content: (NPI 1194356386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194356386 NPI number — MR. ED'S CIRCLE OF TRUST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MR. ED'S CIRCLE OF TRUST, 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:
THE CENTER FOR FAITH BASED FAMILY SERVICES
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:
1194356386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4404 S FLORIDA AVE.
Provider Second Line Business Mailing Address:
SUITE 14
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33813-2124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-583-4766
Provider Business Mailing Address Fax Number:
850-270-6733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4404 S. FLORIDA AVE.
Provider Second Line Business Practice Location Address:
SUITE 14
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33813-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-583-4766
Provider Business Practice Location Address Fax Number:
850-270-6733
Provider Enumeration Date:
01/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SHOEMAKER
Authorized Official First Name:
FRANKLIN
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
863-899-2162

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116677300 . 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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