1659563971 NPI number — CMS IRRV COMPLEX TRUST

Table of content: (NPI 1659563971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659563971 NPI number — CMS IRRV COMPLEX TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CMS IRRV COMPLEX TRUST
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:
SEBRING MEDICAL WALK-IN CLINIC
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:
1659563971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
343 S COMMERCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBRING
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33870-3607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-382-2772
Provider Business Mailing Address Fax Number:
863-382-3172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
343 S COMMERCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBRING
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33870-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-382-2772
Provider Business Practice Location Address Fax Number:
863-382-3172
Provider Enumeration Date:
08/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SERALDE
Authorized Official First Name:
CIRILO
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR/PHYSICIAN
Authorized Official Telephone Number:
863-382-2772

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  ME0043253 , 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: 259715200 . This is a "MEDICAID GROUP MEDIPASS NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: D21429 . This is a "DR.VICTOR SERALDE-UPIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 41214Z . This is a "MEDICARE PROVIDER CIRILO SERALDE FOR SEBRING CLINIC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K2381 . This is a "MEDICARE PTAN GROUP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: D54734 . This is a "DR.CIRILO SERALDE,JR-UPIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1659563971 . This is a "NPI -GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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