1104259449 NPI number — CSI PRIVATE DUTY SERVICES, INC

Table of content: (NPI 1104259449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104259449 NPI number — CSI PRIVATE DUTY SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CSI PRIVATE DUTY SERVICES, 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:
6
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:
1104259449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 S STATE ST FL 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60603-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-762-9999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2646 SW MAPP RD STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34990-2758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-221-9363
Provider Business Practice Location Address Fax Number:
866-961-3463
Provider Enumeration Date:
08/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BONACCORSI
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF LEGAL OFFICER, SECRETARY
Authorized Official Telephone Number:
312-762-9999

Provider Taxonomy Codes

  • Taxonomy code: 3747A0650X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 679119108 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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