1477896991 NPI number — NOVUS MEDICAL DETOX CENTER

Table of content: (NPI 1477896991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477896991 NPI number — NOVUS MEDICAL DETOX CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVUS MEDICAL DETOX CENTER
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:
1477896991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9270 ROYAL PALM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34654-5018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-232-8356
Provider Business Mailing Address Fax Number:
727-232-8408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9270 ROYAL PALM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34654-5018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-232-8356
Provider Business Practice Location Address Fax Number:
727-232-8408
Provider Enumeration Date:
04/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WESCH
Authorized Official First Name:
BRYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
727-232-8356

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  SR51AD2352-01 , 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: 0652AD235201 . This is a "PA GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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