1285679597 NPI number — BEAR CREEK NURSING CENTER, LLC

Table of content: (NPI 1285679597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285679597 NPI number — BEAR CREEK NURSING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAR CREEK NURSING CENTER, LLC
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:
1285679597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8041 STATE ROAD 52
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34667-6726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-863-5488
Provider Business Mailing Address Fax Number:
727-862-9558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8041 STATE ROAD 52
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34667-6726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-863-5488
Provider Business Practice Location Address Fax Number:
727-862-9558
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OWENS-WICKER
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
727-863-5488

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF10460962 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 219410 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 022856700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14773 . This is a "STAYWELL/WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01459 . This is a "UNIVERSAL HC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103501 . This is a "CITRUS HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: L06 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7105581 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 022856700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com