1568463222 NPI number — SANDY RIDGE INVESTORS INC

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 1568463222 NPI number — SANDY RIDGE INVESTORS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDY RIDGE INVESTORS 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:
SANDY RIDGE HEALTH AND REHABILITATION
Provider Other Organization Name Type Code:
3
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:
1568463222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2123 CENTRE POINTE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-4930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-386-2831
Provider Business Mailing Address Fax Number:
850-386-2016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5360 GLOVER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32570-4189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-626-9225
Provider Business Practice Location Address Fax Number:
850-626-5983
Provider Enumeration Date:
08/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-386-2831

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: 022062100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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