1235471368 NPI number — YOUR SECOND HOME ADULT DAY CARE 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 1235471368 NPI number — YOUR SECOND HOME ADULT DAY CARE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUR SECOND HOME ADULT DAY CARE 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:
6
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:
1235471368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3702 N COURTENAY PKWY
Provider Second Line Business Mailing Address:
SUITE 108/110
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-8155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-986-8500
Provider Business Mailing Address Fax Number:
321-986-8444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3702 N COURTENAY PKWY
Provider Second Line Business Practice Location Address:
SUITE 108/110
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32953-8155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-986-8500
Provider Business Practice Location Address Fax Number:
321-986-8444
Provider Enumeration Date:
03/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DOODNAUTH
Authorized Official First Name:
GANGADAI
Authorized Official Middle Name:
SINGH
Authorized Official Title or Position:
ADMINISTRATOR & OWNER
Authorized Official Telephone Number:
321-986-8500

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 690781400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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