1942406475 NPI number — COUNTY OF LAFAYETTE OFFICE CLERK BOARD COUNTY COMMISSIONERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942406475 NPI number — COUNTY OF LAFAYETTE OFFICE CLERK BOARD COUNTY COMMISSIONERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF LAFAYETTE OFFICE CLERK BOARD COUNTY COMMISSIONERS
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:
LAFAYETTE COUNTY RESCUE
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:
1942406475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 88
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAYO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32066-0088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-294-1633
Provider Business Mailing Address Fax Number:
386-294-4242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
136 S.E. INDUSTRIAL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-294-1633
Provider Business Practice Location Address Fax Number:
386-294-4242
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HICKS
Authorized Official First Name:
TREVOR
Authorized Official Middle Name:
Authorized Official Title or Position:
EMS DIRECTOR
Authorized Official Telephone Number:
386-294-1633

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  2655 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 341600000X , with the licence number: 2915 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 341600000X , with the licence number: 2978 , 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: A0600 . This is a "BLUE CROSS / BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 400118400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: SG1611 . This is a "METCARE HEALTH PLANS, INC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 220145 . This is a "AVMED HEALTH PLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 400118400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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