1114955713 NPI number — CENTERWELL HEALTH SERVICES (CERTIFIED), INC.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114955713 NPI number — CENTERWELL HEALTH SERVICES (CERTIFIED), INC.

Employer Identification Number (EIN):

Provider Organization Name:

CENTERWELL HEALTH SERVICES (CERTIFIED), 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 Other Organization Name:

CENTERWELL HOME HEALTH

Provider Other Organization Name Type Code:

3

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:

1114955713

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

12/08/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6330 SPRINT PKWY STE 300

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

OVERLAND PARK

Provider Business Mailing Address State Name:

KS

Provider Business Mailing Address Postal Code:

66211-1157

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1737 N CLYDE MORRIS BLVD STE 110

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DAYTONA BEACH

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

32117-5534

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

386-274-1088

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/30/2006

Authorized Official Last Name:

NICHOLS

Authorized Official First Name:

JOHN

Authorized Official Middle Name:

Authorized Official Title or Position:

AUTHORIZED SIGNATORY

Authorized Official Telephone Number:

386-274-1088

• Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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• Identifier: 107937315 . This is a "G2" identifier . This identifiers is of the category "OTHER".
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• Identifier: 11-3414024 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 146544 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 013100P . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 2196642 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 1016435 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 2117426 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 112645333 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 113414024G . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 027154301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 080053 . This is a "G2" identifier . This identifiers is of the category "OTHER".
• Identifier: 107338 . This is a "G2" identifier . This identifiers is of the category "OTHER".