1386611085 NPI number — FLORIDA DEPARTMENT OF HEALTH

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 1386611085 NPI number — FLORIDA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF HEALTH
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:
6
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:
1386611085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVE OAK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32064-6030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-362-2708
Provider Business Mailing Address Fax Number:
386-362-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 SW VIRGINIA CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32066-4064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-294-1321
Provider Business Practice Location Address Fax Number:
386-294-3876
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALDRON
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
386-362-2708

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 029034300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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