1063141604 NPI number — JOURNEY ABA FLORIDA LLC

Table of content: (NPI 1063141604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063141604 NPI number — JOURNEY ABA FLORIDA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOURNEY ABA FLORIDA LLC
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:
1063141604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
737 MAIN STREET
Provider Second Line Business Mailing Address:
STE 100 PMB 33
Provider Business Mailing Address City Name:
SAFETY HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34695
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-213-8851
Provider Business Mailing Address Fax Number:
727-231-9795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
737 MAIN STREET
Provider Second Line Business Practice Location Address:
STE 100 PMB 33
Provider Business Practice Location Address City Name:
SAFETY HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34695-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-213-8851
Provider Business Practice Location Address Fax Number:
727-231-9795
Provider Enumeration Date:
06/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HAUSMAN
Authorized Official First Name:
JORDAN
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED MEMBER
Authorized Official Telephone Number:
727-798-1253

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115160300 . 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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