1063719136 NPI number — RAYNYODA JACKSON MED WAVIER AGENCY LLC

Table of Contents

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: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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" .

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