1295409423 NPI number — JOHNSON RIVERSIDE FAMILY PRACTICE LLC

Table of content: (NPI 1295409423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295409423 NPI number — JOHNSON RIVERSIDE FAMILY PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSON RIVERSIDE FAMILY PRACTICE 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:
1295409423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 AVENUE J SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORE HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33471-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-946-0284
Provider Business Mailing Address Fax Number:
863-946-0794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43 AVENUE J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORE HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-599-1620
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
NICHOLE
Authorized Official Title or Position:
APRN
Authorized Official Telephone Number:
863-946-0284

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 111570200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".