1679139919 NPI number — ABA SQUAD INC

Table of content: (NPI 1679139919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679139919 NPI number — ABA SQUAD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABA SQUAD 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:
Provider Other Organization Name Type Code:
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:
1679139919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 347720
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-735-3878
Provider Business Mailing Address Fax Number:
786-800-5433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12747 OLIVE BLVD
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-490-8535
Provider Business Practice Location Address Fax Number:
786-800-5433
Provider Enumeration Date:
05/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
VASQUEZ
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
305-290-2493

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003245387A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500069220 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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