1043893704 NPI number — HIDDEN OAKS ALF, INC

Table of content: (NPI 1043893704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043893704 NPI number — HIDDEN OAKS ALF, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIDDEN OAKS ALF, 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:
1043893704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENNINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32053-0180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-938-2097
Provider Business Mailing Address Fax Number:
386-487-0366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7150 NW 22ND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JENNINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32053-2367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-938-2097
Provider Business Practice Location Address Fax Number:
386-487-0366
Provider Enumeration Date:
04/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LAW
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-938-2097

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104310300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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