1124336268 NPI number — FLORIDA DEPARTMENT OF VETERANS' AFFAIRS

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 1124336268 NPI number — FLORIDA DEPARTMENT OF VETERANS' AFFAIRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF VETERANS' AFFAIRS
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:
CLYDE E. LASSEN STATE VETERANS' NURSING HOME
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 Information

NPI Number:
1124336268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4650 STATE ROAD 16
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-0600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-940-2193
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4650 STATE ROAD 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32092-0600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-940-2193
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DAY
Authorized Official First Name:
CLAUDIA
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PROGRAM DIRECTOR, FDVA
Authorized Official Telephone Number:
727-518-3203

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  314000000X , 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: 003204900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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