1447462221 NPI number — COMMUNITY BASED CARE OF SEMINOLE, INC.

Table of content: DR. MARK ELDEN BODMAN DO (NPI 1619986833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447462221 NPI number — COMMUNITY BASED CARE OF SEMINOLE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY BASED CARE OF SEMINOLE, 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:
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:
1447462221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 LAKE MARY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANFORD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-333-8256
Provider Business Mailing Address Fax Number:
407-333-8269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 LAKE MARY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-333-8256
Provider Business Practice Location Address Fax Number:
407-333-8269
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CASEL
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
407-333-8256

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  07-1072-000-06 , 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)





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