1023013729 NPI number — PUTNAM COUNTY ALCOHOL & DRUG COUNCIL, INC.

Table of content: (NPI 1023013729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023013729 NPI number — PUTNAM COUNTY ALCOHOL & DRUG COUNCIL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUTNAM COUNTY ALCOHOL & DRUG COUNCIL, 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:
6
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:
1023013729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 KAY LARKIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32177-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-329-3780
Provider Business Mailing Address Fax Number:
386-385-1269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 KAY LARKIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALATKA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32177-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-329-3780
Provider Business Practice Location Address Fax Number:
386-385-1269
Provider Enumeration Date:
06/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHAIRPERSON BOARD OF DIRECTORS
Authorized Official Telephone Number:
386-325-4714

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X , with the licence number: 0354AD252601 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 38327 . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 360349100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 335268 . This is a "VALUE OPTIONS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 60023030 . This is a "MAGELLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 758545400 . This is a "MEDICAID CARE MGMT" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274738 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 760471800 . This is a "MEDICAID COMP. ACCESS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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