1093017055 NPI number — WAYCHANGERS SERVICES 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 1093017055 NPI number — WAYCHANGERS SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYCHANGERS SERVICES 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:
1093017055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3210 THACKERY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANT CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-731-1975
Provider Business Mailing Address Fax Number:
866-472-9754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 OAK FIELD DR
Provider Second Line Business Practice Location Address:
SUITE 153
Provider Business Practice Location Address City Name:
BRENDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-472-7075
Provider Business Practice Location Address Fax Number:
866-472-9754
Provider Enumeration Date:
11/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTIAN
Authorized Official First Name:
CLAIBORNE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
813-731-1795

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: MH9398 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 766129100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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