1134153836 NPI number — CENTERWELL HEALTH SERVICES (CERTIFIED), INC.

Table of content: (NPI 1134153836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134153836 NPI number — CENTERWELL HEALTH SERVICES (CERTIFIED), INC.

Organization/Personal Information

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'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:
1134153836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 LAGRANDE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE VILLAGES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159-1310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-787-2780
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

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:
352-787-2780

Provider Taxonomy Codes

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

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

  • Identifier: 070417 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00011327202 . 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: 095190 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11-3414024 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112135 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080053 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1019245 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 107512 . 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: 020100 . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017126100 . 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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