1568757854 NPI number — MARIANA NATURAL HEALTH CO

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 1568757854 NPI number — MARIANA NATURAL HEALTH CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIANA NATURAL HEALTH CO
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:
NATURALHEALTH CHOICE
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:
1568757854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2245 NW 40TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32605-1755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-439-8729
Provider Business Mailing Address Fax Number:
352-378-8002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 NW 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32601-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-378-8002
Provider Business Practice Location Address Fax Number:
352-378-8002
Provider Enumeration Date:
06/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KAMBUROV
Authorized Official First Name:
MARIANA
Authorized Official Middle Name:
PAVLOVA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-378-8002

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AP2980 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X , with the licence number: AP2980 , 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: 1972784122 . This is a "NPPES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1568757854 . This is a "NPPES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103683800 . 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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