1407437106 NPI number — AGNES COTTAGE LLC

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 1407437106 NPI number — AGNES COTTAGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGNES COTTAGE LLC
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:
1407437106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10957 LEDGEMENT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDERMERE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34786-6423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-550-2211
Provider Business Mailing Address Fax Number:
407-902-0121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3739 SUNRISE OAKS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32129-8651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-265-4732
Provider Business Practice Location Address Fax Number:
407-902-0121
Provider Enumeration Date:
04/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BYRON
Authorized Official First Name:
ABIOLA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINSTRATOR
Authorized Official Telephone Number:
240-550-2211

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109773100 . 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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