1225503824 NPI number — SABRENA MCCULLOUGH

Table of content: SABRENA MCCULLOUGH (NPI 1225503824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225503824 NPI number — SABRENA MCCULLOUGH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOUGH
Provider First Name:
SABRENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1225503824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/25/2019
NPI Reactivation Date:
05/15/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HUNTLEY OAKS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE PLACID
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33852-7002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-243-1761
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HUNTLEY OAKS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33852-7002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-243-1761
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102624700 . 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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