1457396376 NPI number — MRB ACQUISITION CORP

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 1457396376 NPI number — MRB ACQUISITION CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MRB ACQUISITION CORP
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:
1457396376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19387 US HIGHWAY 19 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33764-3102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-530-7700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1898 S CLYDE MORRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32119-1584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-387-2668
Provider Business Practice Location Address Fax Number:
386-254-2844
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARNHARD
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
727-530-7700

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  32:04483 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 8519 , 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: 022929600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121378400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1014691930001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9266409 AND TAX ID . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5607416 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807182800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200070320A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: R9241 . This is a "BLUE CROSS BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 342165100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027940 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE2695 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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