1033385919 NPI number — INDEPENDENCE-COMMUNITY ACCESS NETWORK, INC

Table of content: (NPI 1033385919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033385919 NPI number — INDEPENDENCE-COMMUNITY ACCESS NETWORK, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENCE-COMMUNITY ACCESS NETWORK, 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:
1033385919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 FLORIDA AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
COCOA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32922-7953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-614-1379
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
274 BREVARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COCOA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32922-7967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-745-2720
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RENK-SCHREIBER
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO, CLINICAL DIRECTOR
Authorized Official Telephone Number:
321-863-5286

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  229742 , 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: 685184396 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 685184398 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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