1801025366 NPI number — FLORIDA PHS LLC

Table of content: (NPI 1801025366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801025366 NPI number — FLORIDA PHS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA PHS 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:
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:
1801025366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9155 CRESTWYN HILLS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38125-8501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-260-4758
Provider Business Mailing Address Fax Number:
901-261-4867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 NE THIRD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1500
Provider Business Practice Location Address City Name:
FT. LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33301-1181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-261-4848
Provider Business Practice Location Address Fax Number:
901-261-4849
Provider Enumeration Date:
07/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
901-261-4858

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003107800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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