1336253020 NPI number — ACV HEALTH SERVICES L L C

Table of content: (NPI 1336253020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336253020 NPI number — ACV HEALTH SERVICES L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACV HEALTH SERVICES L L C
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:
GOOD SAMARITAN CENTER
Provider Other Organization Name Type Code:
3
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:
1336253020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4674
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWLING PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32064-1507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-658-5450
Provider Business Mailing Address Fax Number:
386-658-5111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10676 MARVIN JONES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32064-8242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-658-5550
Provider Business Practice Location Address Fax Number:
386-658-5666
Provider Enumeration Date:
08/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
CRAG
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
386-658-5500

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1178096 , 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: 026876300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: L3Z . This is a "BCBS UB92" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 026876300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".