1083688485 NPI number — SCC GROUP HEALTH CLINIC INCORPORATED

Table of content: (NPI 1083688485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083688485 NPI number — SCC GROUP HEALTH CLINIC INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCC GROUP HEALTH CLINIC INCORPORATED
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:
1083688485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 RICKENBACKER DR
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
SUN CITY CENTER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33573-5332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-634-8980
Provider Business Mailing Address Fax Number:
813-634-2593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 RICKENBACKER DR
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
SUN CITY CENTER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33573-5332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-634-8980
Provider Business Practice Location Address Fax Number:
813-634-2593
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZAK
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
813-634-8980

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22072 . This is a "BC/BS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 050266900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350013655 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: T54819 . This is a "UPIN NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0009673 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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