1063719136 NPI number — RAYNYODA JACKSON MED WAVIER AGENCY LLC

Table of content: (NPI 1063719136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063719136 NPI number — RAYNYODA JACKSON MED WAVIER AGENCY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYNYODA JACKSON MED WAVIER AGENCY 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:
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:
1063719136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 NW 5TH AVE
Provider Second Line Business Mailing Address:
PO BOX 2634
Provider Business Mailing Address City Name:
HIGH SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32643-0418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-433-0350
Provider Business Mailing Address Fax Number:
385-454-4288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 NW 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGH SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32643-0418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-433-0350
Provider Business Practice Location Address Fax Number:
385-454-4288
Provider Enumeration Date:
02/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
RAYNYODA
Authorized Official Middle Name:
SHELONDA
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
386-433-0350

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  6906358 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 691654696 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 691654603 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 691654698 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6906358 . This is a "ADULT FAMILY CARE HOME PROVIDER LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com