1629244629 NPI number — AT HOME OF BREVARD, LLC.

Table of content: (NPI 1629244629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629244629 NPI number — AT HOME OF BREVARD, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AT HOME OF BREVARD, 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:
GOLDEN WINGS WENDEL
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:
1629244629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1351 DARROW RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32908-6248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-676-6331
Provider Business Mailing Address Fax Number:
321-951-2118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3116 WENDEL RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32909-8469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-952-6623
Provider Business Practice Location Address Fax Number:
321-952-6624
Provider Enumeration Date:
04/30/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CULLEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
321-676-6331

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  10779 , 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: 6931120 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".