1386613180 NPI number — LIFE MEDICAL CENTER OF LECANTO,INC

Table of content: (NPI 1386613180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386613180 NPI number — LIFE MEDICAL CENTER OF LECANTO,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE MEDICAL CENTER OF LECANTO,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:
KINNARD CHIROPRACTIC
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:
1386613180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2611 HIGHWAY 44 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INVERNESS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34453-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-726-0554
Provider Business Mailing Address Fax Number:
352-726-3885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2611 HIGHWAY 44 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INVERNESS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34453-3725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-726-0554
Provider Business Practice Location Address Fax Number:
352-726-3885
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KINNARD
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-726-0554

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH6693 , 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: 38954 . This is a "BLUE CROSS & BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004237500 . 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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