1326183377 NPI number — EASTERSEALS NORTHEAST CENTRAL FLORIDA

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 1326183377 NPI number — EASTERSEALS NORTHEAST CENTRAL FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERSEALS NORTHEAST 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:
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:
1326183377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1219 DUNN AVE
Provider Second Line Business Mailing Address:
P.O. BOX 9117
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32114-2405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-255-4568
Provider Business Mailing Address Fax Number:
386-258-7677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 W NEW YORK 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:
32720-5239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-255-4568
Provider Business Practice Location Address Fax Number:
386-258-7677
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
BEVERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
386-255-4568

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  34167 , 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: 8907811 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105186202 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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