1104268085 NPI number — FLORIDA PALMS ACADEMY,INC

Table of content: (NPI 1104268085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104268085 NPI number — FLORIDA PALMS ACADEMY,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA PALMS ACADEMY,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:
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:
1104268085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10001 W OAKLAND PARK BLVD
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33351-6925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-746-5200
Provider Business Mailing Address Fax Number:
954-746-5216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5925 MCKINLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-4560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-963-0991
Provider Business Practice Location Address Fax Number:
954-963-3956
Provider Enumeration Date:
07/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-746-5200

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  44 , 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: 029582516 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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