1316178783 NPI number — NORTHSIDE PHYSICAL THERAPY AND REHABILITATION, INC

Table of content: MRS. STACEY DARLENE PARRENT LPN (NPI 1649586504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316178783 NPI number — NORTHSIDE PHYSICAL THERAPY AND REHABILITATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE PHYSICAL THERAPY AND REHABILITATION, 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:
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:
1316178783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
752 W PLYMOUTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32720-3282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-734-1136
Provider Business Mailing Address Fax Number:
386-734-2262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
752 W PLYMOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32720-3282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-734-1136
Provider Business Practice Location Address Fax Number:
386-734-2262
Provider Enumeration Date:
08/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
386-734-1136

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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