1104579424 NPI number — EPIC COMMUNITY SERVICES, INC.

Table of content: (NPI 1104579424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104579424 NPI number — EPIC COMMUNITY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPIC COMMUNITY 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:
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:
1104579424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 OLD DIXIE HWY
Provider Second Line Business Mailing Address:
SUITE A.
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32084-4190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-829-2273
Provider Business Mailing Address Fax Number:
904-824-0724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3574 US HIGHWAY 1 SOUTH
Provider Second Line Business Practice Location Address:
SUITES 106-111
Provider Business Practice Location Address City Name:
SAINT AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-6466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-829-2273
Provider Business Practice Location Address Fax Number:
904-824-0724
Provider Enumeration Date:
01/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GREENOUGH
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
904-829-2273

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 070827500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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