1659531309 NPI number — PRISON REHABILITATIVE INDUSTRIES DIVERSIFIED ENTERPRISES, INC

Table of content: (NPI 1659531309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659531309 NPI number — PRISON REHABILITATIVE INDUSTRIES DIVERSIFIED ENTERPRISES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRISON REHABILITATIVE INDUSTRIES DIVERSIFIED ENTERPRISES, 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:
P.R.I.D.E BROWARD OPTICAL
Provider Other Organization Name Type Code:
5
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:
1659531309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12425 28TH ST N
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33716-1844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-572-1987
Provider Business Mailing Address Fax Number:
727-570-3378

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20421 SHERIDAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33332-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-523-1766
Provider Business Practice Location Address Fax Number:
813-890-2103
Provider Enumeration Date:
06/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RADANOVICH
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
727-556-3370

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  S. 2220 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 086571100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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