1023071198 NPI number — WINDWARD BEHAVIORAL CARE, INC.

Table of content: (NPI 1023071198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023071198 NPI number — WINDWARD BEHAVIORAL CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINDWARD BEHAVIORAL CARE, 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:
1023071198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2196
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32115-2196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-258-5050
Provider Business Mailing Address Fax Number:
386-252-3506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 S. AMELIA AVENUE
Provider Second Line Business Practice Location Address:
BLDG. A
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32724-5913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-258-5050
Provider Business Practice Location Address Fax Number:
386-252-3506
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENSEN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
386-258-5050

Provider Taxonomy Codes

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

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

  • Identifier: 0299804-01 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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