1245678184 NPI number — BRIDGE OF HOPE CENTRAL FLORIDA

Table of content: (NPI 1245678184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245678184 NPI number — BRIDGE OF HOPE CENTRAL FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE OF HOPE CENTRAL FLORIDA
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:
BRIDGE OF HOPE CENTRAL FLORIDA
Provider Other Organization Name Type Code:
4
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:
1245678184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 452878
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34745-2878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-575-4636
Provider Business Mailing Address Fax Number:
321-250-7425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 KEVSTIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34744-5844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-575-4536
Provider Business Practice Location Address Fax Number:
321-250-7425
Provider Enumeration Date:
06/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OPERATION MANAGER
Authorized Official Telephone Number:
407-575-4636

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 21145 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT 1181 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SA10475 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000867500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000867502 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000867501 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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