1063459295 NPI number — CORNISH THERAPEUTIC CARE INC

Table of content: (NPI 1063459295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063459295 NPI number — CORNISH THERAPEUTIC CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNISH THERAPEUTIC 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:
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:
1063459295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16128 4TH ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDINGTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33708-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-251-8903
Provider Business Mailing Address Fax Number:
727-393-5986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11590 SEMINOLE BLVD
Provider Second Line Business Practice Location Address:
SUITE C-4
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33778-3204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-251-8903
Provider Business Practice Location Address Fax Number:
727-393-5986
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORNISH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
727-251-8903

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT19198 , 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: 887320896 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 889996700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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