1720395759 NPI number — TRIPLE E OT, INC

Table of content: (NPI 1720395759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720395759 NPI number — TRIPLE E OT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIPLE E OT, 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:
1720395759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 S FERDON BLVD
Provider Second Line Business Mailing Address:
SUITE C-1
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32536-5252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-682-8388
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 LAKEVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEFUNIAK SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32433-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-401-1227
Provider Business Practice Location Address Fax Number:
850-892-6994
Provider Enumeration Date:
09/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HYDLE
Authorized Official First Name:
KIM
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OCCUPATIONAL THERAPIST/DIRECTOR
Authorized Official Telephone Number:
850-682-8388

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT5156 , 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: 000124300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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