1831474923 NPI number — SUNDANCE THERAPY INC

Table of content: (NPI 1831474923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831474923 NPI number — SUNDANCE THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNDANCE THERAPY 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:
1831474923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 CHIEFTAIN ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE PLACID
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33852-8858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-414-0211
Provider Business Mailing Address Fax Number:
863-465-2152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
147 TOWER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33852-6836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-465-9992
Provider Business Practice Location Address Fax Number:
863-465-9906
Provider Enumeration Date:
10/20/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RITACCO
Authorized Official First Name:
MEREDITH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
863-414-0211

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , 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: 812362400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 889870700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: LBE19 . This is a "FL BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".