1457480444 NPI number — PRC ASSOCIATES 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 1457480444 NPI number — PRC ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRC ASSOCIATES 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:
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:
1457480444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1671 N CLYDE MORRIS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32117-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-274-2977
Provider Business Mailing Address Fax Number:
386-274-2997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 REBECCA LN
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-8351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-456-1160
Provider Business Practice Location Address Fax Number:
386-456-1162
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALIK
Authorized Official First Name:
VINOD
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-274-2977

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 272955501 . 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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